Provider Demographics
NPI:1962732420
Name:DYER, CHARLENE D (MA, LPC)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:D
Last Name:DYER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:D
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LPCA
Mailing Address - Street 1:5200 PARK RD STE 218B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3650
Mailing Address - Country:US
Mailing Address - Phone:866-700-1606
Mailing Address - Fax:866-338-5921
Practice Address - Street 1:5200 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:866-388-5921
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC121328Medicaid