Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 1213 | AZ |
Y | 103TC0700X | Clinical Psychologist | 1213 | AZ |
NPI | 1003938176 |
---|---|
Provider Name | Dr. Charles Brady Wilson |
First Address | Scottsdale, AZ 85260-3005 |
Second Address | Scottsdale, AZ 85260-3007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 20/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
188531100 | DOL - OWCP (01) | AZ |