MEDICARE: ADRIENNE CHARLESTON LPA

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	103T00000X	Psychologist	4299	NC
2	103TC1900X	Counseling Psychologist	4299	NC
3	103TC0700X	Clinical Psychologist	4299	NC

General Provider Information

NPI Number	:	1720335417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADRIENNE CHARLESTON LPA

Provider Business Mailing Address
First Line	:	PO BOX 2372
Second Line	:
City	:	GARNER
State	:	NC
Zip	:	27529-2372
Country	:	US
Telephone Number	:	919-346-4619
Fax Number	:

Provider Business Practice Location Address
First Line	:	5878 FARINGDON PL
Second Line	:	STE 11B
City	:	RALEIGH
State	:	NC
Zip	:	27609-4589
Country	:	US
Telephone Number	:	919-346-4617
Fax Number	:

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

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	05/06/2019

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Directions to “ ADRIENNE CHARLESTON LPA” Practice Location

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