Provider Demographics
NPI:1013296300
Name:THIEDE, CHARLTON (LAC)
Entity Type:Individual
Prefix:
First Name:CHARLTON
Middle Name:
Last Name:THIEDE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S POPLAR ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-6017
Mailing Address - Country:US
Mailing Address - Phone:501-279-9220
Mailing Address - Fax:501-279-9450
Practice Address - Street 1:403 S POPLAR ST
Practice Address - Street 2:SUITE A
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-6017
Practice Address - Country:US
Practice Address - Phone:501-279-9220
Practice Address - Fax:501-279-9450
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1504056101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health