Provider Demographics
NPI:1053141135
Name:SANDIFER, CHARLES BENJAMIN (EDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BENJAMIN
Last Name:SANDIFER
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S OAK ST STE 301
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-2248
Mailing Address - Country:US
Mailing Address - Phone:765-584-7602
Mailing Address - Fax:
Practice Address - Street 1:325 S OAK ST STE 301
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-2248
Practice Address - Country:US
Practice Address - Phone:765-584-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN000018009103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool