Provider Demographics
NPI:1083345557
Name:WACHTLER, CHARLOTTE ANNE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANNE
Last Name:WACHTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2049 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-4221
Practice Address - Country:US
Practice Address - Phone:619-465-7303
Practice Address - Fax:619-469-4325
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAAMFT130157106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty