Provider Demographics
NPI:1346494895
Name:DORAM, CHARLES ANTHONY (CSAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:DORAM
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 ROYAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1535
Mailing Address - Country:US
Mailing Address - Phone:608-661-2829
Mailing Address - Fax:608-661-0907
Practice Address - Street 1:2829 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-1535
Practice Address - Country:US
Practice Address - Phone:608-661-2829
Practice Address - Fax:608-661-0907
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)