Provider Demographics
NPI:1982735189
Name:EASTLICK, CHARLES WILLIAM (LICDC, LPC, MED)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:EASTLICK
Suffix:
Gender:M
Credentials:LICDC, LPC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2348
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:5108 SANDY LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2738
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0005142-SUPV101YP2500X
OHLICDC.001351101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310734113OtherTAX I.D.
OHMC0713Medicaid