Provider Demographics
NPI:1497950422
Name:CHARLES P WAITZ PHD
Entity Type:Organization
Organization Name:CHARLES P WAITZ PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:WAITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:609-953-1222
Mailing Address - Street 1:639 STOKES RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-3003
Mailing Address - Country:US
Mailing Address - Phone:609-953-1222
Mailing Address - Fax:609-714-0095
Practice Address - Street 1:639 STOKES RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-3003
Practice Address - Country:US
Practice Address - Phone:609-953-1222
Practice Address - Fax:609-714-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00109300103TC0700X
PAPS002060L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
086946Medicare ID - Type Unspecified