Provider Demographics
NPI:1215577226
Name:PLANCK, CHARLIE MARIE (BCBA LBA)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:MARIE
Last Name:PLANCK
Suffix:
Gender:F
Credentials:BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 TWIN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-7416
Mailing Address - Country:US
Mailing Address - Phone:269-355-5662
Mailing Address - Fax:
Practice Address - Street 1:646 TWIN LAKE DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-7416
Practice Address - Country:US
Practice Address - Phone:269-355-5662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001971103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician