Provider Demographics
NPI:1497051502
Name:BABCOCK, CHARLES ALAN (MED)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALAN
Last Name:BABCOCK
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 486
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-0486
Mailing Address - Country:US
Mailing Address - Phone:717-575-7444
Mailing Address - Fax:717-948-6108
Practice Address - Street 1:301 GROFF AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2820
Practice Address - Country:US
Practice Address - Phone:717-575-7444
Practice Address - Fax:717-948-6108
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 007207L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS 007207LOtherLICENSE PSYCHOLOGY
PA753110313OtherEIN