Provider Demographics
NPI:1831371640
Name:CHARLEBOIS, ETTA LOUISE (LISW-S)
Entity type:Individual
Prefix:MS
First Name:ETTA
Middle Name:LOUISE
Last Name:CHARLEBOIS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15618 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8507
Mailing Address - Country:US
Mailing Address - Phone:513-460-5191
Mailing Address - Fax:
Practice Address - Street 1:434 HOME STREET
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-9321
Practice Address - Country:US
Practice Address - Phone:937-378-2979
Practice Address - Fax:937-378-2970
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0005459101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health