Basic Information
| Provider Information | |||||||||
| NPI: | 1518580158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GINN | ||||||||
| FirstName: | CHARLIE | ||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 38 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205623323 | ||||||||
| FaxNumber: | 5205625223 | ||||||||
| Practice Location | |||||||||
| Address1: | 291 W CASA BLANCA RD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2020 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10-114 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.