Provider Demographics
NPI:1659576817
Name:DEPRIEST, CHARLES LEE (PC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:DEPRIEST
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 SHERWOOD DR W
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-4465
Mailing Address - Country:US
Mailing Address - Phone:740-345-7484
Mailing Address - Fax:
Practice Address - Street 1:975 S SUNBURY RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-9345
Practice Address - Country:US
Practice Address - Phone:614-865-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC70007091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC70007091OtherLICENSE