Provider Demographics
NPI:1700963741
Name:ALCORN, CHARLES EDGAR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDGAR
Last Name:ALCORN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:CHAD
Other - Middle Name:E
Other - Last Name:ALCORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:460 N MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5176
Mailing Address - Country:US
Mailing Address - Phone:630-469-4699
Mailing Address - Fax:
Practice Address - Street 1:460 N MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5176
Practice Address - Country:US
Practice Address - Phone:630-469-4699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical