Provider Demographics
NPI:1508856642
Name:O'BANNON, CHARLES RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:O'BANNON
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 1:123 E POWELL BLVD
Mailing Address - Street 2:STE. 212
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7622
Mailing Address - Country:US
Mailing Address - Phone:503-618-8041
Mailing Address - Fax:503-618-8052
Practice Address - Street 1:123 E POWELL BLVD
Practice Address - Street 2:STE. 212
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7622
Practice Address - Country:US
Practice Address - Phone:503-618-8041
Practice Address - Fax:503-618-8052
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1044103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR143267Medicare PIN
OR114401Medicare ID - Type Unspecified