Provider Demographics
NPI:1942715313
Name:PASTOOR, CHARLES CORNELIUS (MA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CORNELIUS
Last Name:PASTOOR
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W ELGIN ST
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-2229
Mailing Address - Country:US
Mailing Address - Phone:479-236-6834
Mailing Address - Fax:
Practice Address - Street 1:747 HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965-1508
Practice Address - Country:US
Practice Address - Phone:918-723-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health