Basic Information
| Provider Information | |||||||||
| NPI: | 1396839825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLEY | ||||||||
| FirstName: | CAMILLIA | ||||||||
| MiddleName: | LASHAWN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482081105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139613700 | ||||||||
| FaxNumber: | 3139613769 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482081105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139613700 | ||||||||
| FaxNumber: | 3139613769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802078417 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6802078417 | 01 | MI | STATE LICENSE NUMBER | OTHER |