Provider Demographics
NPI:1104136571
Name:UPTON, CHARLES TYLER (LISAC, PLC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TYLER
Last Name:UPTON
Suffix:
Gender:M
Credentials:LISAC, PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 E. FORT LOWELL RD
Mailing Address - Street 2:STE 202
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2378
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:721 N. FOURTH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705
Practice Address - Country:US
Practice Address - Phone:520-202-1870
Practice Address - Fax:520-202-1889
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC10856101YA0400X
AZLPC11260101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional