1568515989 NPI number — MR. CHARLES FRANKLIN BLEAKMORE MA COUNSELING PSYCHO

Table of content: (NPI 1629075205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568515989 NPI number — MR. CHARLES FRANKLIN BLEAKMORE MA COUNSELING PSYCHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLEAKMORE
Provider First Name:
CHARLES
Provider Middle Name:
FRANKLIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA COUNSELING PSYCHO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568515989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 MALLARD DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43082-1066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-890-4166
Provider Business Mailing Address Fax Number:
614-436-1194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 E WILSON BRIDGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORTHINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43085-2324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-436-1188
Provider Business Practice Location Address Fax Number:
614-436-1194
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  E-718 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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