Provider Demographics
NPI:1033132899
Name:LODL, CHARLES MATHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MATHEW
Last Name:LODL
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 1:11501 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3466
Mailing Address - Country:US
Mailing Address - Phone:262-241-8901
Mailing Address - Fax:262-241-8907
Practice Address - Street 1:11501 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3466
Practice Address - Country:US
Practice Address - Phone:262-241-8901
Practice Address - Fax:262-241-8907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI857-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39050600Medicaid
WI88722Medicare ID - Type Unspecified