Provider Demographics
NPI:1609598093
Name:COTTON, CHARLES DAYTON JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAYTON
Last Name:COTTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W BIANCHI RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-7132
Mailing Address - Country:US
Mailing Address - Phone:209-888-5088
Mailing Address - Fax:
Practice Address - Street 1:3422 W HAMMER LN STE ABC
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-5535
Practice Address - Country:US
Practice Address - Phone:209-888-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390017AN103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)