Provider Demographics
NPI:1073084737
Name:SUMLER, CHARLISHA (RADT R1329651118)
Entity Type:Individual
Prefix:
First Name:CHARLISHA
Middle Name:
Last Name:SUMLER
Suffix:
Gender:F
Credentials:RADT R1329651118
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CYPRESS AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-3834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1760 FREMONT BLVD STE E1
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-3615
Practice Address - Country:US
Practice Address - Phone:831-393-9316
Practice Address - Fax:831-899-6565
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARADTR1329651118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1329651118OtherCCAPP