Provider Demographics
NPI:1518183540
Name:WHETSELL, CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WHETSELL
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:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-535-1211
Mailing Address - Fax:919-746-7603
Practice Address - Street 1:1424 MONTCLAIR RD
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-2208
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL817103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-76172OtherBCBS OF AL #
ALS11203Medicare ID - Type Unspecified
AL515-76172OtherBCBS OF AL #