Provider Demographics
NPI:1265992879
Name:HOMER, CHARLES RUSSEL (RBT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RUSSEL
Last Name:HOMER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-7408
Mailing Address - Country:US
Mailing Address - Phone:561-932-3938
Mailing Address - Fax:
Practice Address - Street 1:1340 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-7408
Practice Address - Country:US
Practice Address - Phone:561-932-3938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-79673106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty