Provider Demographics
NPI:1043652944
Name:CHARLTON, SCOTT MICHAEL
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:CHARLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 BLUE GUM AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-1052
Mailing Address - Country:US
Mailing Address - Phone:209-573-1981
Mailing Address - Fax:209-525-5498
Practice Address - Street 1:2215 BLUE GUM AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-1052
Practice Address - Country:US
Practice Address - Phone:209-573-1981
Practice Address - Fax:209-525-5498
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAIMF89161106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist