MEDICARE: KELLY LOUISE CHARLES MSW, LCSW, CSOTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C008679	NC
2	1041C0700X	Clinical Social Worker	LCSW117886	CA

General Provider Information

NPI Number	:	1467791186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LOUISE CHARLES MSW, LCSW, CSOTS

Provider Business Mailing Address
First Line	:	1235 EAST BLVD STE E
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-5876
Country	:	US
Telephone Number	:	866-736-6408
Fax Number	:	980-225-0506

Provider Business Practice Location Address
First Line	:	1235 EAST BLVD STE E
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-5876
Country	:	US
Telephone Number	:	866-736-6408
Fax Number	:	980-225-0506

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	05/18/2025

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