Provider Demographics
NPI:1245081389
Name:NGO, CHARLES BENJAMIN (PMHNP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BENJAMIN
Last Name:NGO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 HAWK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-7307
Mailing Address - Country:US
Mailing Address - Phone:714-277-7886
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-3101
Practice Address - Country:US
Practice Address - Phone:860-545-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10.218533163W00000X
CT013347363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
2024028681OtherAACN