Provider Demographics
NPI:1881704047
Name:DAVIS, CHARLES EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:DAVIS
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:PO BOX 3908
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-3908
Mailing Address - Country:US
Mailing Address - Phone:708-431-2245
Mailing Address - Fax:
Practice Address - Street 1:1145 WESTGATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1089
Practice Address - Country:US
Practice Address - Phone:708-431-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
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