Provider Demographics
NPI:1679515274
Name:CLOW, CHARLES TREVON (PHD, LMHC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TREVON
Last Name:CLOW
Suffix:
Gender:M
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N CAUSEWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-5298
Mailing Address - Country:US
Mailing Address - Phone:386-428-4564
Mailing Address - Fax:386-428-4539
Practice Address - Street 1:221 N CAUSEWAY
Practice Address - Street 2:SUITE B
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5298
Practice Address - Country:US
Practice Address - Phone:386-428-4564
Practice Address - Fax:386-428-4539
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health