Provider Demographics
NPI:1083374136
Name:BEWLEY, CHARLES ADRIAN JR (MS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ADRIAN
Last Name:BEWLEY
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4265
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91617-0265
Mailing Address - Country:US
Mailing Address - Phone:323-377-7857
Mailing Address - Fax:
Practice Address - Street 1:12501 CHANDLER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-1955
Practice Address - Country:US
Practice Address - Phone:818-821-6012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124649101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health