Provider Demographics
NPI:1043360100
Name:DRURY, CHARLES BURTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BURTON
Last Name:DRURY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 CATALINA STREET
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651
Mailing Address - Country:US
Mailing Address - Phone:949-584-6909
Mailing Address - Fax:949-497-6909
Practice Address - Street 1:1402 CATALINA STREET
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651
Practice Address - Country:US
Practice Address - Phone:949-584-6909
Practice Address - Fax:949-497-6909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7692103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7692Medicare ID - Type Unspecified