Provider Demographics
NPI:1548861008
Name:DAVITT, CHARLIE ARTHUR
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:ARTHUR
Last Name:DAVITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W BRADLEY PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W BRADLEY PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:847-868-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015155101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health