Provider Demographics
NPI:1033204771
Name:GERLACH, CHARLES EDWIN (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWIN
Last Name:GERLACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 REED RD STE C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3074
Mailing Address - Country:US
Mailing Address - Phone:614-442-1300
Mailing Address - Fax:614-442-1308
Practice Address - Street 1:4700 REED RD STE C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3074
Practice Address - Country:US
Practice Address - Phone:614-442-1300
Practice Address - Fax:614-442-1308
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3978103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGECP 09453Medicare PIN