Provider Demographics
NPI:1609031400
Name:WOFFORD, CHARLIE JEAN (MD BCBA)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JEAN
Last Name:WOFFORD
Suffix:
Gender:F
Credentials:MD BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 KINCAID BRIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-7116
Mailing Address - Country:US
Mailing Address - Phone:803-635-1052
Mailing Address - Fax:
Practice Address - Street 1:1136 KINCAID BRIDGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-7116
Practice Address - Country:US
Practice Address - Phone:803-635-1052
Practice Address - Fax:803-712-9724
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
SC32464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC324644Medicaid