Provider Demographics
NPI:1538345335
Name:CHARLES, BERNADETTE M (LISW LICDC)
Entity type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:M
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LISW LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 DENISE DR
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-1606
Mailing Address - Country:US
Mailing Address - Phone:330-678-2646
Mailing Address - Fax:
Practice Address - Street 1:695 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1474
Practice Address - Country:US
Practice Address - Phone:440-286-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH892705101YA0400X
OHI18391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)