Provider Demographics
NPI:1295977023
Name:CHARLES, ELIZABETH ROSE (LMHC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 RIVERINA DR
Mailing Address - Street 2:UNIT E
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8158
Mailing Address - Country:US
Mailing Address - Phone:617-594-0325
Mailing Address - Fax:850-462-1612
Practice Address - Street 1:9910 GUIDY LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1670
Practice Address - Country:US
Practice Address - Phone:850-462-1611
Practice Address - Fax:850-462-1612
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12182101YM0800X
101YP1600X, 106H00000X
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010365700Medicaid