Healthcare Provider Details

I. General information

NPI: 1679138465
Provider Name (Legal Business Name): CHARLENE MESA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5522 LONE STAR PKWY STE 330
SAN ANTONIO TX
78253-6719
US

IV. Provider business mailing address

2424 GOLD CANYON DR APT 1312
SAN ANTONIO TX
78259-3664
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-4990
  • Fax: 210-614-4991
Mailing address:
  • Phone: 361-877-2174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number77134
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number77134
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: