Provider Demographics
NPI:1063820801
Name:KIRK, CHARLES SR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KIRK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 S PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-6215
Mailing Address - Country:US
Mailing Address - Phone:765-635-3826
Mailing Address - Fax:
Practice Address - Street 1:4346 S PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-6215
Practice Address - Country:US
Practice Address - Phone:765-635-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor