Provider Demographics
NPI:1134197593
Name:PAHL, CHARLENE ANN (LMSW ACSW)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:ANN
Last Name:PAHL
Suffix:
Gender:F
Credentials:LMSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 KENT ST STE 5
Mailing Address - Street 2:CHILD AND FAMILY WELLNESS COUNSELING CTR
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875
Mailing Address - Country:US
Mailing Address - Phone:517-647-4600
Mailing Address - Fax:517-647-4600
Practice Address - Street 1:212 KENT ST STE 5
Practice Address - Street 2:CHILD AND FAMILY WELLNESS COUNSELING CTR
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875
Practice Address - Country:US
Practice Address - Phone:517-647-4600
Practice Address - Fax:517-647-4600
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010623871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008948970OtherBCBS OF MI
ON76880Medicare ID - Type Unspecified