Provider Demographics
NPI:1558928911
Name:VIGILIA, CHARLES GRANT
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GRANT
Last Name:VIGILIA
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 1:18350 MOUNT LANGLEY ST STE 220
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6912
Mailing Address - Country:US
Mailing Address - Phone:714-378-2620
Mailing Address - Fax:
Practice Address - Street 1:18350 MOUNT LANGLEY ST STE 220
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6912
Practice Address - Country:US
Practice Address - Phone:714-378-2620
Practice Address - Fax:714-378-2631
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician