Healthcare Provider Details

I. General information

NPI: 1699300012
Provider Name (Legal Business Name): CHARLENE CROSS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 ROUTE 23 STE 3
WINDHAM NY
12496-1510
US

IV. Provider business mailing address

PO BOX 176
WINDHAM NY
12496-0176
US

V. Phone/Fax

Practice location:
  • Phone: 518-321-5369
  • Fax:
Mailing address:
  • Phone: 585-481-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096030
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number106275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: