Provider Demographics
NPI:1861956567
Name:MATLOCK, CHARITY (LCMHC)
Entity type:Individual
Prefix:MS
First Name:CHARITY
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:ELIZABETH MAE
Other - Last Name:MATLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCMHC
Mailing Address - Street 1:PO BOX 4962
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-4962
Mailing Address - Country:US
Mailing Address - Phone:704-360-3637
Mailing Address - Fax:
Practice Address - Street 1:122 GATEWAY BLVD STE C
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5544
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health