Healthcare Provider Details

I. General information

NPI: 1992289961
Provider Name (Legal Business Name): CHARLES CARTER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 MONROE RD
DE PERE WI
54115-8399
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11456-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0019077
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: