Provider Demographics
NPI:1063445807
Name:SMITH, CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SMITH
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 1:1630 S BROWNLEE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3134
Mailing Address - Country:US
Mailing Address - Phone:361-886-6900
Mailing Address - Fax:361-888-8358
Practice Address - Street 1:3733 S PORT AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-4532
Practice Address - Country:US
Practice Address - Phone:361-886-6900
Practice Address - Fax:361-888-8358
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22499103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81879PMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.