Healthcare Provider Details

I. General information

NPI: 1952673865
Provider Name (Legal Business Name): CHARLAINE MARIE ALLESANDRINE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLAINE MARIE ST. CHARLES

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 11/13/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HOLMES AVENUE
WATESBURY CT
06710-2419
US

IV. Provider business mailing address

75 WEST STREET
DANBURY CT
06810-6528
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-2868
  • Fax: 203-755-9975
Mailing address:
  • Phone: 203-748-5689
  • Fax: 203-755-9975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6511
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: