Provider Demographics
NPI:1831494194
Name:ANDERSON, CHARLES ROBERT (BS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1892 HOLLOW OAK DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-9745
Mailing Address - Country:US
Mailing Address - Phone:405-564-5253
Mailing Address - Fax:
Practice Address - Street 1:1892 HOLLOW OAK DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-9745
Practice Address - Country:US
Practice Address - Phone:405-564-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst