Provider Demographics
NPI:1700054806
Name:CHILES, THERON LEON
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:LEON
Last Name:CHILES
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 1:9100 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4814
Mailing Address - Country:US
Mailing Address - Phone:310-644-3659
Mailing Address - Fax:
Practice Address - Street 1:9100 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4814
Practice Address - Country:US
Practice Address - Phone:310-644-3659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)