Provider Demographics
NPI:1275862849
Name:SWAN, CHARLEY LEIGH (MA)
Entity Type:Individual
Prefix:
First Name:CHARLEY
Middle Name:LEIGH
Last Name:SWAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WAVECREST AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-6213
Mailing Address - Country:US
Mailing Address - Phone:910-988-2725
Mailing Address - Fax:
Practice Address - Street 1:11 WAVECREST AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-6213
Practice Address - Country:US
Practice Address - Phone:910-988-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83292106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist