Provider Demographics
NPI:1962789065
Name:MALLETT, CHARLES ALBERT (BA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALBERT
Last Name:MALLETT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8640 NEALY LN
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-7018
Mailing Address - Country:US
Mailing Address - Phone:618-656-3972
Mailing Address - Fax:
Practice Address - Street 1:1430 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2303
Practice Address - Country:US
Practice Address - Phone:314-206-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0011228854171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator