Provider Demographics
NPI:1669348744
Name:ADDY, CHARMON K
Entity type:Individual
Prefix:
First Name:CHARMON
Middle Name:K
Last Name:ADDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 W ROOSEVELT ST UNIT 169
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5022
Mailing Address - Country:US
Mailing Address - Phone:910-585-6206
Mailing Address - Fax:
Practice Address - Street 1:11175 W ROOSEVELT ST UNIT 169
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5022
Practice Address - Country:US
Practice Address - Phone:910-585-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician