Provider Demographics
NPI:1720496730
Name:CHARLES R OBANNON
Entity Type:Organization
Organization Name:CHARLES R OBANNON
Other - Org Name:RENAISSANCE COUNSELING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:503-618-8041
Mailing Address - Street 1:31090 SE DIVISION DR
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-9451
Mailing Address - Country:US
Mailing Address - Phone:503-618-8041
Mailing Address - Fax:503-618-8052
Practice Address - Street 1:31090 SE DIVISION DR
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-9451
Practice Address - Country:US
Practice Address - Phone:503-618-8041
Practice Address - Fax:503-618-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty