Healthcare Provider Details

I. General information

NPI: 1558463430
Provider Name (Legal Business Name): CHARLES L. KOAH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1769 JAMESTOWN RD STE 104
WILLIAMSBURG VA
23185-2300
US

IV. Provider business mailing address

4712 LADY SLIPPER PATH
WILLIAMSBURG VA
23188-2400
US

V. Phone/Fax

Practice location:
  • Phone: 757-871-3693
  • Fax: 757-220-1476
Mailing address:
  • Phone: 757-871-3693
  • Fax: 757-220-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001333
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: