Provider Demographics
NPI:1194264119
Name:VINCENT, CHARLENE MISCHELLE (MA)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:MISCHELLE
Last Name:VINCENT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-9251
Mailing Address - Country:US
Mailing Address - Phone:304-367-9412
Mailing Address - Fax:
Practice Address - Street 1:2000 COOMBS FARM RD STE 106
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1126
Practice Address - Country:US
Practice Address - Phone:304-381-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1833101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional