Provider Demographics
NPI:1023336237
Name:CASE, CHARLES
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:CASE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BRANT WALK
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11697-1820
Mailing Address - Country:US
Mailing Address - Phone:718-474-4475
Mailing Address - Fax:
Practice Address - Street 1:2928 W 36TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1410
Practice Address - Country:US
Practice Address - Phone:718-372-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00057385Medicaid