Provider Demographics
NPI:1821073909
Name:DOYLE, CHARLES GLENN (PSYD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GLENN
Last Name:DOYLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 N DUQUESNE RD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1509
Mailing Address - Country:US
Mailing Address - Phone:417-782-1443
Mailing Address - Fax:417-782-3240
Practice Address - Street 1:1230 N DUQUESNE RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1509
Practice Address - Country:US
Practice Address - Phone:417-782-1443
Practice Address - Fax:417-782-3240
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004033755103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495853517Medicaid
MO495853517Medicaid