Provider Demographics
NPI:1205308665
Name:CARTER, CHARESE
Entity type:Individual
Prefix:
First Name:CHARESE
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6456 NW FRIENDLY CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1303
Mailing Address - Country:US
Mailing Address - Phone:772-621-0123
Mailing Address - Fax:772-673-7860
Practice Address - Street 1:6456 NW FRIENDLY CIR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1303
Practice Address - Country:US
Practice Address - Phone:772-621-0123
Practice Address - Fax:772-673-7860
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-22-59264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102065700Medicaid