Provider Demographics
NPI:1427170703
Name:CHARLES T BACHUS, PA
Entity type:Organization
Organization Name:CHARLES T BACHUS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:609-921-6899
Mailing Address - Street 1:6 WENCZEL DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-3155
Mailing Address - Country:US
Mailing Address - Phone:609-921-6899
Mailing Address - Fax:
Practice Address - Street 1:166 BUNN DR STE 101
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2800
Practice Address - Country:US
Practice Address - Phone:609-921-6899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00150100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087091Medicare ID - Type Unspecified