Provider Demographics
NPI:1881126472
Name:CHARLES, KELLYE II (R1244990317)
Entity type:Individual
Prefix:
First Name:KELLYE
Middle Name:
Last Name:CHARLES
Suffix:II
Gender:F
Credentials:R1244990317
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E AVENUE K4
Mailing Address - Street 2:SUITE B
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4678
Mailing Address - Country:US
Mailing Address - Phone:661-874-4680
Mailing Address - Fax:661-793-7231
Practice Address - Street 1:104 E AVENUE K4
Practice Address - Street 2:SUITE B
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4678
Practice Address - Country:US
Practice Address - Phone:661-874-4680
Practice Address - Fax:661-793-7231
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1244990317101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)