MEDICARE: IFONIE CHARLES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	29041	FL

General Provider Information

NPI Number	:	1952256216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IFONIE CHARLES

Provider Business Mailing Address
First Line	:	3957 SW LAFFITE ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3660
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8505 S US HIGHWAY 1
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-3346
Country	:	US
Telephone Number	:	772-353-2485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ IFONIE CHARLES ” Practice Location

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