Provider Demographics
NPI:1912154824
Name:ELIAS, CHARLES D (LCSW, PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:ELIAS
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SAO AUGUSTINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3609
Mailing Address - Country:US
Mailing Address - Phone:415-444-0787
Mailing Address - Fax:415-444-0699
Practice Address - Street 1:9 SAO AUGUSTINE WAY
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3609
Practice Address - Country:US
Practice Address - Phone:415-444-0787
Practice Address - Fax:415-444-0699
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS32591041C0700X
MI68010640861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical