MEDICARE: DR. CHAREL LEE KHOL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3455	OH
2	103TC2200X	Clinical Child & Adolescent Psychologist	3455	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34 1593635	OTHER	OH	TAX ID

General Provider Information

NPI Number	:	1417946237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHAREL LEE KHOL PH.D.

Provider Business Mailing Address
First Line	:	3918 CLOCK POINTE TRL
Second Line	:	SUITE 104
City	:	STOW
State	:	OH
Zip	:	44224-2989
Country	:	US
Telephone Number	:	216-839-2273
Fax Number	:	216-896-0735

Provider Business Practice Location Address
First Line	:	6133 ROCKSIDE RD
Second Line	:	SUITE 207
City	:	INDEPENDENCE
State	:	OH
Zip	:	44131-2223
Country	:	US
Telephone Number	:	216-520-5969
Fax Number	:	216-520-5098

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	03/15/2013

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