Healthcare Provider Details

I. General information

NPI: 1083833255
Provider Name (Legal Business Name): CHARLES ROBERT LOVE MDIV, LMHC, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 CHARLESTOWN RD
NEW ALBANY IN
47150-9426
US

IV. Provider business mailing address

4925 CHARLESTOWN RD
NEW ALBANY IN
47150-9426
US

V. Phone/Fax

Practice location:
  • Phone: 812-941-9200
  • Fax: 812-941-9205
Mailing address:
  • Phone: 812-941-9200
  • Fax: 812-941-9205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0725
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002436A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: