Provider Demographics
NPI:1174695787
Name:CHARLES, TONEY LEE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:TONEY
Middle Name:LEE
Last Name:CHARLES
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:301 N WELLINGTON ST
Mailing Address - Street 2:PO BOX 8317
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-3335
Mailing Address - Country:US
Mailing Address - Phone:903-938-4476
Mailing Address - Fax:902-938-4125
Practice Address - Street 1:301 NORTH WELLINGTON ST.
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-3230
Practice Address - Country:US
Practice Address - Phone:903-938-4476
Practice Address - Fax:902-938-4125
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31395103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86649AOtherBLUE CROSS BLUE SHIELD
TX146705201Medicaid
TX83194PMedicare ID - Type Unspecified