Provider Demographics
NPI:1104008283
Name:MADSEN, CHARLES H JR (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:MADSEN
Suffix:JR
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 1:1254 OCALA RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-1548
Mailing Address - Country:US
Mailing Address - Phone:850-575-8954
Mailing Address - Fax:
Practice Address - Street 1:1254 OCALA RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32304-1548
Practice Address - Country:US
Practice Address - Phone:850-575-8954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2886103TC0700X
GAPSY1989103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTAN 74311ZMedicare UPIN