Provider Demographics
NPI:1164833646
Name:ARCHER, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ARCHER
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 1:705 ORCHARD HILL RD
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1318
Mailing Address - Country:US
Mailing Address - Phone:740-588-5544
Mailing Address - Fax:740-455-4325
Practice Address - Street 1:160 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3518
Practice Address - Country:US
Practice Address - Phone:740-454-9751
Practice Address - Fax:740-455-4325
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUA1015311103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool