Provider Demographics
NPI:1265429260
Name:CHARLES, THOMAS L (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9443
Mailing Address - Country:US
Mailing Address - Phone:608-339-4511
Mailing Address - Fax:608-339-4593
Practice Address - Street 1:108 E NORTH ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9443
Practice Address - Country:US
Practice Address - Phone:608-339-4511
Practice Address - Fax:608-339-4593
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4207-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39587400Medicaid