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General NPI Number Information
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NPI Number | 1033654504
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Entity Type | Individual
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Provider Name | CHARLES CORUM BCBA
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Gender | Male
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Dates
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Enumeration Date | 12/19/2016
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Last Update Date | 11/16/2023
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Provider Practice Location Address
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Address Line | 510 W 10TH ST
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City | LYNN HAVEN
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State | FL
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Zip | 32444-2329
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Country | US
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Telephone | 575-649-6044
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Fax |
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Provider Business Mailing Address
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Address Line | 6926 PITTSBURGH ST
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City | PANAMA CITY
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State | FL
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Zip | 32404
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Country | US
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Telephone | 575-649-6044
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-19-38776
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 247200000X
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-19-38776
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License Number State |
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