Basic Information
| Provider Information | |||||||||
| NPI: | 1326422890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | MICHON | ||||||||
| MiddleName: | RICA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHARLES | ||||||||
| OtherFirstName: | MICHON | ||||||||
| OtherMiddleName: | RICA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 N LOOP 1604 E STE 175 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782321231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102713630 | ||||||||
| FaxNumber: | 2102719414 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N LOOP 1604 E STE 175 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782321231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102713630 | ||||||||
| FaxNumber: | 2102719414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2015 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 68122 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.