Healthcare Provider Details

I. General information

NPI: 1275048613
Provider Name (Legal Business Name): CHARLES SHAFFER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

IV. Provider business mailing address

PO BOX 55
WALTON KY
41094-0055
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5823
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.2005738
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: