Provider Demographics
NPI:1679372312
Name:CHARLES, MATILLA K
Entity type:Individual
Prefix:
First Name:MATILLA
Middle Name:K
Last Name:CHARLES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 DALLAS HWY SW STE 202-1200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 FRANKLIN GTWY SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7749
Practice Address - Country:US
Practice Address - Phone:678-968-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician