Provider Demographics
NPI:1689868937
Name:KAUFMAN, CHARLES R (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 SHOUP AVE W
Mailing Address - Street 2:BOX 5591
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5045
Mailing Address - Country:US
Mailing Address - Phone:208-734-8844
Mailing Address - Fax:208-734-8844
Practice Address - Street 1:464 SHOUP AVE W
Practice Address - Street 2:BOX 5591
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5045
Practice Address - Country:US
Practice Address - Phone:208-734-8844
Practice Address - Fax:208-734-8844
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1680168Medicare PIN