Provider Demographics
NPI:1184811200
Name:KOONCE, CHARLES I (LMHC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:I
Last Name:KOONCE
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 45TH AVE NE APT 409
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-4420
Mailing Address - Country:US
Mailing Address - Phone:253-238-8781
Mailing Address - Fax:
Practice Address - Street 1:4602 45TH AVE NE APT 409
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-4420
Practice Address - Country:US
Practice Address - Phone:253-238-8781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00009907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health