=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861663825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANNY CHARLES LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2008
-----------------------------------------------------
Last Update Date | 11/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1094 POPLAR AVE. SERENITY RECOVERY CENTERS
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-521-1131
-----------------------------------------------------
Fax | 901-746-9643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1094 POPLAR AVE. SERENITY RECOVERY CENTERS
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-521-1131
-----------------------------------------------------
Fax | 901-746-9643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1811-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------