Provider Demographics
NPI:1003667924
Name:WHITE, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 W CULLOM AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:315-244-7344
Mailing Address - Fax:
Practice Address - Street 1:395 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-4180
Practice Address - Country:US
Practice Address - Phone:099-353-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501107661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical