Provider Demographics
NPI:1659361731
Name:WASSERMAN, CHARLES BRENT SR (PH D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRENT
Last Name:WASSERMAN
Suffix:SR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19542 MAYALL ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-1014
Mailing Address - Country:US
Mailing Address - Phone:818-718-9705
Mailing Address - Fax:818-718-2276
Practice Address - Street 1:19542 MAYALL ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-1014
Practice Address - Country:US
Practice Address - Phone:818-718-9705
Practice Address - Fax:818-718-2276
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL57220Medicaid
CA00PL57220OtherLOS ANGELES COUNTY DMH