Basic Information
| Provider Information | |||||||||
| NPI: | 1689020687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DEWAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 KALISTE SALOOM RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372347109 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4951 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183401535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.