Provider Demographics
NPI:1174238703
Name:MEREDITH, CHARLES BRIAN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRIAN
Last Name:MEREDITH
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 1:3408 SOUTH ATLANTIC AVE.
Mailing Address - Street 2:PMB 1052
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118
Mailing Address - Country:US
Mailing Address - Phone:386-767-3752
Mailing Address - Fax:
Practice Address - Street 1:3408 SOUTH ATLANTIC AVE.
Practice Address - Street 2:PMB 1052
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-253447106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-253447OtherBACB