Basic Information
| Provider Information | |||||||||
| NPI: | 1497808224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | GSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 175 | ||||||||
| Address2: | |||||||||
| City: | SLAUGHTER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707770175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256839866 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11990 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5748 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5748 | 01 | LA | LA SOCIAL WORKER EXAMINER | OTHER |