Provider Demographics
NPI:1497948707
Name:CHARLES CARLISE EDD PSYCHOLOGIST
Entity Type:Organization
Organization Name:CHARLES CARLISE EDD PSYCHOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GASPER
Authorized Official - Last Name:CARLISE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:602-622-2933
Mailing Address - Street 1:2345 E THOMAS RD
Mailing Address - Street 2:SUITE 295
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7848
Mailing Address - Country:US
Mailing Address - Phone:602-622-2933
Mailing Address - Fax:602-957-3063
Practice Address - Street 1:2345 E THOMAS RD
Practice Address - Street 2:SUITE 295
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7848
Practice Address - Country:US
Practice Address - Phone:602-622-2933
Practice Address - Fax:602-957-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3229251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare