Provider Demographics
NPI:1285755652
Name:ECKELMAN, CHARLES CLEARY (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CLEARY
Last Name:ECKELMAN
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 1:259 PAPIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3715
Mailing Address - Country:US
Mailing Address - Phone:314-968-9942
Mailing Address - Fax:
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:SUITE 421T
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-721-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0044103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical