Provider Demographics
NPI:1013369628
Name:MASSIE, CHARLES (LPC, LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MASSIE
Suffix:
Gender:M
Credentials:LPC, LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2012
Mailing Address - Country:US
Mailing Address - Phone:618-877-4420
Mailing Address - Fax:
Practice Address - Street 1:5000 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2012
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018007090101YP2500X
IL180.011349101YP2500X
IL32660101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)