Provider Demographics
NPI:1780071977
Name:SPATES, CHARLES RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:SPATES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:RICHARD
Other - Last Name:SPATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:4715 CARVER DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9504
Mailing Address - Country:US
Mailing Address - Phone:269-599-6869
Mailing Address - Fax:269-387-4550
Practice Address - Street 1:1000 OAKLAND DR
Practice Address - Street 2:PSYCHOLOGY CLINIC
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1282
Practice Address - Country:US
Practice Address - Phone:269-387-8302
Practice Address - Fax:269-387-4550
Is Sole Proprietor?:No
Enumeration Date:2015-04-25
Last Update Date:2015-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002505103T00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service