Provider Demographics
NPI:1013008002
Name:BURCHELL, CHARLES (PH D)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:BURCHELL
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 CAROL SUE AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-5100
Mailing Address - Country:US
Mailing Address - Phone:504-392-3498
Mailing Address - Fax:504-392-4694
Practice Address - Street 1:1581 CAROL SUE AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5100
Practice Address - Country:US
Practice Address - Phone:504-392-3498
Practice Address - Fax:504-392-4694
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA56190Medicare ID - Type Unspecified