Provider Demographics
NPI:1548221351
Name:MOSHONTZ, CHARLES MICHAEL (MFT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:MOSHONTZ
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10516 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4964
Mailing Address - Country:US
Mailing Address - Phone:310-508-2545
Mailing Address - Fax:
Practice Address - Street 1:10516 SANTA MONICA BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4964
Practice Address - Country:US
Practice Address - Phone:310-508-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38767106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist