Healthcare Provider Details

I. General information

NPI: 1699373340
Provider Name (Legal Business Name): CHARLIE BALDWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6127 FAIR OAKS BLVD
CARMICHAEL CA
95608-4818
US

IV. Provider business mailing address

3297 TEA ROSE DR
EL DORADO HILLS CA
95762-6568
US

V. Phone/Fax

Practice location:
  • Phone: 916-974-8090
  • Fax:
Mailing address:
  • Phone: 530-363-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: