Healthcare Provider Details

I. General information

NPI: 1811103633
Provider Name (Legal Business Name): CHARLES HARLAN WUTH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 BLANCHARD PKWY
ALLENHURST NJ
07711-1304
US

IV. Provider business mailing address

608 BLANCHARD PKWY
ALLENHURST NJ
07711-1304
US

V. Phone/Fax

Practice location:
  • Phone: 732-517-1051
  • Fax:
Mailing address:
  • Phone: 732-517-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC01378600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: