Provider Demographics
NPI:1902064868
Name:SPELLMANN, CHARLES M (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:SPELLMANN
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 1:10498 LOOMIS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:DEVALLS BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:72041
Mailing Address - Country:US
Mailing Address - Phone:870-998-7206
Mailing Address - Fax:
Practice Address - Street 1:790 ROBERTS DRIVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-367-2461
Practice Address - Fax:870-367-1690
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7515P103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56446Medicare PIN