Healthcare Provider Details

I. General information

NPI: 1669990529
Provider Name (Legal Business Name): CHARLES R. MYERS PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 AIRPORT RD
SOUTH BURLINGTON VT
05403-6432
US

IV. Provider business mailing address

30 AIRPORT RD
SOUTH BURLINGTON VT
05403-6432
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-0040
  • Fax: 802-658-0216
Mailing address:
  • Phone: 802-658-0040
  • Fax: 802-658-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number048.0000691
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: