Provider Demographics
NPI:1154438166
Name:WILSON, CHARLES JOSEPH (EDD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:WILSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SKIPPACK PIKE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-2148
Mailing Address - Country:US
Mailing Address - Phone:215-542-1466
Mailing Address - Fax:215-643-0486
Practice Address - Street 1:501 SKIPPACK PIKE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2148
Practice Address - Country:US
Practice Address - Phone:215-542-1466
Practice Address - Fax:215-643-0486
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS001278L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist