Provider Demographics
NPI:1043043359
Name:BUSSARD, CHARLES RYAN (LPC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RYAN
Last Name:BUSSARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6545 MARKET AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2430
Mailing Address - Country:US
Mailing Address - Phone:404-313-4079
Mailing Address - Fax:
Practice Address - Street 1:8899 BROOKSIDE AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-7112
Practice Address - Country:US
Practice Address - Phone:513-759-9744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health