Provider Demographics
NPI:1699564617
Name:GASTON, CHARLICE E
Entity type:Individual
Prefix:
First Name:CHARLICE
Middle Name:E
Last Name:GASTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2102
Mailing Address - Country:US
Mailing Address - Phone:614-680-4058
Mailing Address - Fax:
Practice Address - Street 1:1219 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2102
Practice Address - Country:US
Practice Address - Phone:614-680-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator