Provider Demographics
NPI:1699313957
Name:DAMRON, CHARLIE SHANNON (LSW)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:SHANNON
Last Name:DAMRON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5177
Mailing Address - Fax:
Practice Address - Street 1:292 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2374
Practice Address - Country:US
Practice Address - Phone:419-663-3737
Practice Address - Fax:419-663-5096
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701723101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health