Healthcare Provider Details

I. General information

NPI: 1710061189
Provider Name (Legal Business Name): CHARLOTTE S OBANNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 E 22ND ST # ST10E
TUCSON AZ
85710-6426
US

IV. Provider business mailing address

7301 E 22ND ST # ST10E
TUCSON AZ
85710-6426
US

V. Phone/Fax

Practice location:
  • Phone: 520-260-2174
  • Fax:
Mailing address:
  • Phone: 520-260-2174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW4154
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: