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General NPI Number Information
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NPI Number | 1619285269
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Entity Type | Organization
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Legal Business Name | CHARLES E. DAVIS, PH.D., P.C.
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Dates
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Enumeration Date | 09/16/2010
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Last Update Date | 09/16/2010
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Provider Practice Location Address
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Address Line | 1010 LAKE ST SUITE 109
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City | OAK PARK
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State | IL
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Zip | 60301-1147
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Country | US
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Telephone | 708-431-2245
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Fax | 708-383-0198
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Provider Business Mailing Address
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Address Line | 1010 LAKE ST SUITE 109
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City | OAK PARK
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State | IL
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Zip | 60301-1147
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Country | US
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Telephone | 708-431-2245
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Fax | 708-383-0198
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Authorized Official
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Title or Position | PRESIDENT AND REGISTERED AGENT
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Name | DR. CHARLES E. DAVIS
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Credential | PH.D.
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Telephone | 708-431-2245
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071003271
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License Number State | IL
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