Basic Information
| Provider Information | |||||||||
| NPI: | 1063982866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARIS COUNSELING PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1841 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727301841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794668385 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 128 SOUTHWINDS RD STE 5&6 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727308678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792676934 | ||||||||
| FaxNumber: | 8667983345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2018 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRUSING | ||||||||
| AuthorizedOfficialFirstName: | MINDY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4794668385 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1588835110 | 01 | AR | MINDY GRUSING | OTHER |