Healthcare Provider Details

I. General information

NPI: 1821362153
Provider Name (Legal Business Name): CHARLES DOUGLAS PRINCE LPC, ALPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/18/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

IV. Provider business mailing address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.1801567
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number276481
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number123
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2158
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: