Provider Demographics
NPI:1336126507
Name:DILLION, CHARLES A (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:DILLION
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 1:2086 FARIWAY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319
Mailing Address - Country:US
Mailing Address - Phone:404-325-7405
Mailing Address - Fax:
Practice Address - Street 1:2089 FAIRWAY CIRCLE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319
Practice Address - Country:US
Practice Address - Phone:678-216-0247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0799103T00000X
GA799103T00000X, 103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA504370Medicare ID - Type Unspecified