Healthcare Provider Details

I. General information

NPI: 1245081389
Provider Name (Legal Business Name): CHARLES BENJAMIN NGO PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVE
HARTFORD CT
06102-3101
US

IV. Provider business mailing address

332 HAWK VALLEY DR
TRAVELERS REST SC
29690-7307
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-7295
  • Fax:
Mailing address:
  • Phone: 714-277-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number013347
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10.218533
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: