Healthcare Provider Details

I. General information

NPI: 1174911366
Provider Name (Legal Business Name): WAYNE CHARLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W 25TH ST
BALTIMORE MD
21218-5003
US

IV. Provider business mailing address

21 W 25TH ST
BALTIMORE MD
21218-5003
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-1717
  • Fax: 410-889-4167
Mailing address:
  • Phone: 410-366-1717
  • Fax: 410-889-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: