Provider Demographics
NPI:1457820425
Name:CHARLES, VICKI ACHAN
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:ACHAN
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ACHAN
Other - Last Name:CHARLES-GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CHARLES-GONZALEZ
Mailing Address - Street 1:1660 HOTEL CIR N STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2801
Mailing Address - Country:US
Mailing Address - Phone:619-481-3840
Mailing Address - Fax:
Practice Address - Street 1:1660 HOTEL CIR N STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2801
Practice Address - Country:US
Practice Address - Phone:619-481-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA1200991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator