Provider Demographics
NPI:1003938176
Name:WILSON, CHARLES BRADY (PDD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRADY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9316 E RAINTREE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3005
Mailing Address - Country:US
Mailing Address - Phone:480-778-0202
Mailing Address - Fax:480-778-0204
Practice Address - Street 1:9316 E RAINTREE DR
Practice Address - Street 2:STE 130
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3007
Practice Address - Country:US
Practice Address - Phone:480-778-0202
Practice Address - Fax:480-778-0204
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ188531100OtherDOL - OWCP
AZ188531100OtherDOL - OWCP