Healthcare Provider Details

I. General information

NPI: 1285238626
Provider Name (Legal Business Name): MR. CHARLES C SUCKINAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 FIRST AVE
KETCHIKAN AK
99901-5804
US

IV. Provider business mailing address

PO BOX 7475
KETCHIKAN AK
99901-2475
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-4664
  • Fax: 907-885-6613
Mailing address:
  • Phone: 907-225-4664
  • Fax: 907-885-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: