Provider Demographics
NPI:1477631943
Name:YEARGAN, CHARLES B (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:YEARGAN
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 1:129 MAIN ST
Mailing Address - Street 2:RM. 608
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4615
Mailing Address - Country:US
Mailing Address - Phone:304-255-0900
Mailing Address - Fax:304-255-0900
Practice Address - Street 1:129 MAIN ST
Practice Address - Street 2:RM. 608
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4615
Practice Address - Country:US
Practice Address - Phone:304-255-0900
Practice Address - Fax:304-255-0900
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV166103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165176000Medicaid
WV0165176000Medicaid