=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063737468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT M CHARLES M.DIV.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2010
-----------------------------------------------------
Last Update Date | 03/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1534 TREMONT ST
-----------------------------------------------------
City | ROXBURY CROSSING
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02120-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-306-6812
-----------------------------------------------------
Fax | 617-718-2724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 SILVER BROOK RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02186-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-594-0641
-----------------------------------------------------
Fax | 617-696-8849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------