Provider Demographics
NPI:1962739474
Name:YATES, CHARLES JASON (LCSW, LCAS, CCS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JASON
Last Name:YATES
Suffix:
Gender:M
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EDGEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27260-4319
Mailing Address - Country:US
Mailing Address - Phone:336-991-1567
Mailing Address - Fax:336-886-4160
Practice Address - Street 1:102 CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-6804
Practice Address - Country:US
Practice Address - Phone:336-991-1567
Practice Address - Fax:336-886-4160
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1548101YA0400X
NCC0075641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112113Medicaid