Provider Demographics
NPI:1164637062
Name:WILLAMS, CHARLENE (CP)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WILLAMS
Suffix:
Gender:F
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11726 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 680
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-442-9286
Mailing Address - Fax:
Practice Address - Street 1:11726 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 680
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049
Practice Address - Country:US
Practice Address - Phone:310-442-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15823103T00000X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15823Medicare PIN