Provider Demographics
NPI:1144708603
Name:ANDERSON, CHARITY JUNE (CPS)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:JUNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:
Other - Last Name:SYRUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 76112
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80970-6112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 CLAY BROOK DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-5532
Practice Address - Country:US
Practice Address - Phone:405-657-8627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCCPS-20838405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCPS-20838OtherNORTH CAROLINA ADDICTIONS SPECIALIST PROFESSIONAL PRACTICE BOARD