Healthcare Provider Details

I. General information

NPI: 1720903065
Provider Name (Legal Business Name): IAN CHRISTIAN CHARLTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 TOD PL NW
WARREN OH
44485-2475
US

IV. Provider business mailing address

1212 TOD PL NW
WARREN OH
44485-2475
US

V. Phone/Fax

Practice location:
  • Phone: 330-469-6822
  • Fax:
Mailing address:
  • Phone: 330-469-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.196773
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: