Healthcare Provider Details

I. General information

NPI: 1750303475
Provider Name (Legal Business Name): CHARLES W WASHAM JR. D.MIN, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2734 CHANCELLOR DR SUITE 202
CRESTVIEW HILLS KY
41017-3487
US

IV. Provider business mailing address

2734 CHANCELLOR DR SUITE 202
CRESTVIEW HILLS KY
41017-3487
US

V. Phone/Fax

Practice location:
  • Phone: 859-982-9009
  • Fax: 859-341-3709
Mailing address:
  • Phone: 859-982-9009
  • Fax: 859-341-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003127
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000269
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number103679
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: