Provider Demographics
NPI:1548937535
Name:NORTHSTAR LICENSED PROFESSIONAL CLINICAL COUNSELOR, INC
Entity type:Organization
Organization Name:NORTHSTAR LICENSED PROFESSIONAL CLINICAL COUNSELOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:UKAOMA
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF PSYCHOLOGY
Authorized Official - Phone:760-270-9200
Mailing Address - Street 1:1642 LAS CASITAS DR. 2503
Mailing Address - Street 2:
Mailing Address - City:BORREGO SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92004
Mailing Address - Country:US
Mailing Address - Phone:704-668-6401
Mailing Address - Fax:888-270-0801
Practice Address - Street 1:74710 HIGHWAY 111 STE 102
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3820
Practice Address - Country:US
Practice Address - Phone:760-270-9200
Practice Address - Fax:888-270-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty