Healthcare Provider Details

I. General information

NPI: 1497950422
Provider Name (Legal Business Name): CHARLES P WAITZ PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 STOKES RD SUITE 203
MEDFORD NJ
08055-3003
US

IV. Provider business mailing address

639 STOKES RD SUITE 203
MEDFORD NJ
08055-3003
US

V. Phone/Fax

Practice location:
  • Phone: 609-953-1222
  • Fax: 609-714-0095
Mailing address:
  • Phone: 609-953-1222
  • Fax: 609-714-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS002060L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00109300
License Number StateNJ

VIII. Authorized Official

Name: DR. CHARLES P WAITZ
Title or Position: CLINICAL PSYCHOLOGIST OWNER
Credential: PHD
Phone: 609-953-1222