Healthcare Provider Details

I. General information

NPI: 1336699909
Provider Name (Legal Business Name): CHARLES WILLIAMS LISW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ATCHESON ST
COLUMBUS OH
43203-1353
US

IV. Provider business mailing address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1708
US

V. Phone/Fax

Practice location:
  • Phone: 614-252-4941
  • Fax: 855-908-2509
Mailing address:
  • Phone: 614-445-8131
  • Fax: 614-545-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberI.9538
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number964525
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0009538
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: