Provider Demographics
NPI:1346482577
Name:CHARLES, LISA A (MSED)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41521 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1803
Mailing Address - Country:US
Mailing Address - Phone:804-447-8049
Mailing Address - Fax:804-447-8049
Practice Address - Street 1:4613 VALLEY CREST DR
Practice Address - Street 2:#301
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112
Practice Address - Country:US
Practice Address - Phone:804-447-8049
Practice Address - Fax:804-447-8049
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0601360103T00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103T00000XBehavioral Health & Social Service ProvidersPsychologist