Provider Demographics
NPI:1033654504
Name:CORUM, CHARLES (BCBA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CORUM
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6926 PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404
Mailing Address - Country:US
Mailing Address - Phone:575-649-6044
Mailing Address - Fax:
Practice Address - Street 1:510 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2329
Practice Address - Country:US
Practice Address - Phone:575-649-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-38776103K00000X
FL247200000X106S00000X
1-19-38776103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician