Provider Demographics
NPI:1710280771
Name:KNUDSEN, CHARLES G
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01944-1152
Mailing Address - Country:US
Mailing Address - Phone:412-956-4332
Mailing Address - Fax:
Practice Address - Street 1:460 TOTTEN POND RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1991
Practice Address - Country:US
Practice Address - Phone:781-895-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst