=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053141135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES BENJAMIN SANDIFER ED.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2024
-----------------------------------------------------
Last Update Date | 08/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 S OAK ST STE 301
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47394-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-584-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 S OAK ST STE 301
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47394-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-584-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 000018009
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------