Provider Demographics
NPI:1790773463
Name:CHARBONEAU, GREGORY J (EDD, BCN, BCB)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:CHARBONEAU
Suffix:
Gender:M
Credentials:EDD, BCN, BCB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 E. 17TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-5136
Mailing Address - Country:US
Mailing Address - Phone:509-838-8066
Mailing Address - Fax:800-594-8305
Practice Address - Street 1:3157 E. 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-5136
Practice Address - Country:US
Practice Address - Phone:509-838-8066
Practice Address - Fax:800-594-8305
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2046103TC0700X
WAWA.LIC2046103G00000X
103T00000X, 103TB0200X, 103TC2200X, 103TH0004X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
80159590OtherAPA#
WA911983795Medicare UPIN