Provider Demographics
NPI:1700074341
Name:CHARBONNEAU, LORI JILL (LICSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JILL
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 HEARTWOOD CIR SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-6245
Mailing Address - Country:US
Mailing Address - Phone:701-871-0490
Mailing Address - Fax:
Practice Address - Street 1:2401 46TH AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4829
Practice Address - Country:US
Practice Address - Phone:701-699-4052
Practice Address - Fax:701-989-7030
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND024385OtherBLUE CROSS BLUE SHIELD
ND054517Medicaid
NDN712941Medicare PIN