Provider Demographics
NPI:1508917279
Name:BRILES, CHARLES WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BRILES
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 1:350 N WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2678
Mailing Address - Country:US
Mailing Address - Phone:520-873-3495
Mailing Address - Fax:520-873-5162
Practice Address - Street 1:350 N WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2678
Practice Address - Country:US
Practice Address - Phone:520-873-3495
Practice Address - Fax:520-873-5162
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1609103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020321Medicaid
030011Medicare ID - Type Unspecified