Provider Demographics
NPI:1659343580
Name:SLAGEN, CHARLES J (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:SLAGEN
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 1:16 CLARKE ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4988
Mailing Address - Country:US
Mailing Address - Phone:781-402-2442
Mailing Address - Fax:
Practice Address - Street 1:16 CLARKE ST
Practice Address - Street 2:SUITE 21
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4988
Practice Address - Country:US
Practice Address - Phone:781-402-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-04
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4833103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04589Medicare Oscar/Certification