Healthcare Provider Details

I. General information

NPI: 1316106313
Provider Name (Legal Business Name): CHARLES THOMAS M.ED., LPC, LCAS, CS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 CELANDINE CT
CHARLOTTE NC
28213-9265
US

IV. Provider business mailing address

11400 CELANDINE CT
CHARLOTTE NC
28213-9265
US

V. Phone/Fax

Practice location:
  • Phone: 704-509-6787
  • Fax:
Mailing address:
  • Phone: 704-509-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1311
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number533
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4447
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS7046
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: