Provider Demographics
NPI:1790549426
Name:OLIVER, CHARLES IV (PYSD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:OLIVER
Suffix:IV
Gender:M
Credentials:PYSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 ROCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1875
Mailing Address - Country:US
Mailing Address - Phone:248-764-9875
Mailing Address - Fax:
Practice Address - Street 1:2501 ROCHESTER CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1875
Practice Address - Country:US
Practice Address - Phone:248-891-8380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6351004590103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical