Healthcare Provider Details

I. General information

NPI: 1609598093
Provider Name (Legal Business Name): CHARLES DAYTON COTTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3422 W HAMMER LN STE ABC
STOCKTON CA
95219-5535
US

IV. Provider business mailing address

102 W BIANCHI RD
STOCKTON CA
95207-7132
US

V. Phone/Fax

Practice location:
  • Phone: 209-888-5088
  • Fax:
Mailing address:
  • Phone: 209-888-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number390017AN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: