Provider Demographics
NPI:1871097915
Name:CHARLES, DEIONTRE
Entity type:Individual
Prefix:
First Name:DEIONTRE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S UNION ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5612
Mailing Address - Country:US
Mailing Address - Phone:337-942-9292
Mailing Address - Fax:
Practice Address - Street 1:1310 S UNION ST STE 2
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5612
Practice Address - Country:US
Practice Address - Phone:337-942-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health