Provider Demographics
NPI:1275154932
Name:CHARLES, BREANA
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:CHARLES
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 1:200 SKILES BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-7321
Mailing Address - Country:US
Mailing Address - Phone:800-578-7906
Mailing Address - Fax:
Practice Address - Street 1:8939 S SEPULVEDA BLVD STE 320
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3647
Practice Address - Country:US
Practice Address - Phone:800-578-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician