Provider Demographics
NPI:1548806201
Name:RICARD, CHARLENE (BI)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:RICARD
Suffix:
Gender:F
Credentials:BI
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:
Other - Last Name:HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5348
Mailing Address - Country:US
Mailing Address - Phone:208-553-8650
Mailing Address - Fax:
Practice Address - Street 1:1215 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5348
Practice Address - Country:US
Practice Address - Phone:208-553-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0004105Medicaid