Basic Information
Provider Information | |||||||||
NPI: | 1043752587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLDEN | ||||||||
FirstName: | CHARKELA | ||||||||
MiddleName: | JENEA GASTON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ED.S., LPC, NCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GASTON | ||||||||
OtherFirstName: | CHARKELA | ||||||||
OtherMiddleName: | JENEA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ED.S., LPC, NCC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 UNIVERSITY PKWY | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312065145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784712985 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 UNIVERSITY PKWY | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312065145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784712985 | ||||||||
FaxNumber: | 4784715730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2016 | ||||||||
LastUpdateDate: | 01/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APC005189 | GA | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC009996 | GA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.