Provider Demographics
NPI:1376754549
Name:COULL, CHARLES EDWARD JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:COULL
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1174
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92781-1174
Mailing Address - Country:US
Mailing Address - Phone:714-598-8123
Mailing Address - Fax:949-387-1830
Practice Address - Street 1:17852 17TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2100
Practice Address - Country:US
Practice Address - Phone:714-598-8123
Practice Address - Fax:949-387-1830
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19977106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist