Provider Demographics
NPI:1154335032
Name:NORD, CHARLES (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:NORD
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 1:2150 PEACHFORD RD STE E
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6521
Mailing Address - Country:US
Mailing Address - Phone:770-457-2759
Mailing Address - Fax:770-483-5456
Practice Address - Street 1:2150 PEACHFORD RD STE E
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6521
Practice Address - Country:US
Practice Address - Phone:770-457-2759
Practice Address - Fax:770-483-5456
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2011-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00233472AMedicaid
GA68921Medicare UPIN