Provider Demographics
NPI:1134751704
Name:MEAD, CHARLES JAMES (LPCA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAMES
Last Name:MEAD
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3920
Mailing Address - Country:US
Mailing Address - Phone:203-556-4672
Mailing Address - Fax:
Practice Address - Street 1:2505 MAIN ST STE 231
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5839
Practice Address - Country:US
Practice Address - Phone:203-375-5782
Practice Address - Fax:203-375-3048
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional