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General NPI Number Information
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NPI Number | 1104188374
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Entity Type | Individual
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Provider Name | MARK W. CHARLES PHD
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Gender | Male
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Dates
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Enumeration Date | 06/13/2012
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 34930 MARCIA RD APT C
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City | CATHEDRAL CITY
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State | CA
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Zip | 92234-6979
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Country | US
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Telephone | 414-322-0333
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Fax |
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Provider Business Mailing Address
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Address Line | 34930 MARCIA RD APT C
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City | CATHEDRAL CITY
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State | CA
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Zip | 92234-6979
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Country | US
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Telephone | 414-322-0333
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY30407
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License Number State | CA
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