Provider Demographics
NPI:1164597886
Name:BUCHBAUER, CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BUCHBAUER
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 1:21 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07821-4514
Mailing Address - Country:US
Mailing Address - Phone:973-729-0272
Mailing Address - Fax:
Practice Address - Street 1:1433 RINGWOOD AVE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1520
Practice Address - Country:US
Practice Address - Phone:973-839-2119
Practice Address - Fax:973-616-4193
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100419300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0073148Medicaid
NJ0073148Medicaid