Provider Demographics
NPI:1730529165
Name:CHARLES, ANDREA L (LICSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2031
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-4031
Mailing Address - Country:US
Mailing Address - Phone:509-254-5053
Mailing Address - Fax:509-769-3500
Practice Address - Street 1:920 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2079
Practice Address - Country:US
Practice Address - Phone:509-254-5053
Practice Address - Fax:509-769-3500
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW350661041C0700X
WALW607378301041C0700X
IDLMSW-33024104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW60737830OtherLICENSE
IDLCSW - 35066OtherLICENSE