Basic Information
| Provider Information | |||||||||
| NPI: | 1639522527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W BURLEIGH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532101548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148285617 | ||||||||
| FaxNumber: | 4146431018 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 W BURLEIGH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148285617 | ||||||||
| FaxNumber: | 4146431018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2016 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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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 | 101YP2500X | 2697-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 16837-130 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.