Provider Demographics
NPI:1922100015
Name:CLOSSON, CHARLES WESLEY LEE (PSYD D MIN MFT)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY LEE
Last Name:CLOSSON
Suffix:
Gender:M
Credentials:PSYD D MIN MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 PLATTE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:951-688-0532
Mailing Address - Fax:951-637-8465
Practice Address - Street 1:11280 PLATTE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505
Practice Address - Country:US
Practice Address - Phone:951-688-0532
Practice Address - Fax:951-637-8465
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC12542106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist