Provider Demographics
NPI:1730157801
Name:WHEATON, CHARLES HOWARD (PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HOWARD
Last Name:WHEATON
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 1:2240 BELLEAIR RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-1706
Mailing Address - Country:US
Mailing Address - Phone:727-535-0468
Mailing Address - Fax:727-535-2588
Practice Address - Street 1:2240 BELLEAIR RD
Practice Address - Street 2:SUITE 170
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-1706
Practice Address - Country:US
Practice Address - Phone:727-535-0468
Practice Address - Fax:727-535-2588
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2942103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98371Medicaid
P00407182OtherRAILROAD MEDICARE
FL98371Medicaid