Provider Demographics
NPI:1891947065
Name:KREUTER, CHARLES DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:KREUTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BAUCHET ST
Mailing Address - Street 2:IRC/JMHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2907
Mailing Address - Country:US
Mailing Address - Phone:213-473-6119
Mailing Address - Fax:
Practice Address - Street 1:450 BAUCHET ST
Practice Address - Street 2:IRC/JMHS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2907
Practice Address - Country:US
Practice Address - Phone:213-473-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-18
Last Update Date:2008-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4703103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical