Provider Demographics
NPI:1700218039
Name:VANDERKOLK, CHARLES JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:VANDERKOLK
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 1:2 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-9308
Mailing Address - Country:US
Mailing Address - Phone:828-484-9767
Mailing Address - Fax:828-484-9614
Practice Address - Street 1:2 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28787-9308
Practice Address - Country:US
Practice Address - Phone:828-484-9767
Practice Address - Fax:828-484-9614
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2106103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist