Provider Demographics
NPI:1376661108
Name:CHARETTE, MARK RAYMOND (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:CHARETTE
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 1:2700 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219
Mailing Address - Country:US
Mailing Address - Phone:315-506-9559
Mailing Address - Fax:315-487-7073
Practice Address - Street 1:2700 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219
Practice Address - Country:US
Practice Address - Phone:315-506-9559
Practice Address - Fax:315-487-7073
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011214103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0586Medicare ID - Type Unspecified