Provider Demographics
NPI:1073788758
Name:BUGH, CHARLES RANDEL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RANDEL
Last Name:BUGH
Suffix:
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 1:609 SPURGEON ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-1655
Mailing Address - Country:US
Mailing Address - Phone:812-279-3591
Mailing Address - Fax:
Practice Address - Street 1:609 SPURGEON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-1655
Practice Address - Country:US
Practice Address - Phone:812-279-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000805A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39000805AOtherMENTAL HEALTH COUNSELOR LICENSE
IN072460OtherSIHO PIN