MEDICARE: CHARLES WHEATON PHD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY2942	FL

General Provider Information

NPI Number	:	1609041920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES WHEATON PHD PA

Provider Business Mailing Address
First Line	:	2240 BELLEAIR ROAD
Second Line	:	SUITE 170
City	:	CLEARWATER
State	:	FL
Zip	:	33764-1706
Country	:	US
Telephone Number	:	727-535-0468
Fax Number	:	727-535-2588

Provider Business Practice Location Address
First Line	:	2240 BELLEAIR ROAD
Second Line	:	SUITE 170
City	:	CLEARWATER
State	:	FL
Zip	:	33764-1706
Country	:	US
Telephone Number	:	727-535-0468
Fax Number	:	727-535-2588

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES WHEATON
Credential	:	PHD
Telephone Number	:	727-535-0468

Provider Enumeration Date	:	04/28/2008
Last Update Date	:	04/28/2008

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