Provider Demographics
NPI:1437655420
Name:MCWELLS, CHARLES EDWARD
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:MCWELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1629
Mailing Address - Country:US
Mailing Address - Phone:213-626-6411
Mailing Address - Fax:
Practice Address - Street 1:470 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1629
Practice Address - Country:US
Practice Address - Phone:213-626-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN3626194Medicaid