Provider Demographics
NPI:1205248143
Name:ALLEN, CHARLES WILLIAM II (MA, MFTI)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:ALLEN
Suffix:II
Gender:M
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 MANITOBA ST
Mailing Address - Street 2:#256
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8644
Mailing Address - Country:US
Mailing Address - Phone:310-838-3640
Mailing Address - Fax:
Practice Address - Street 1:11500 OLYMPIC AVE
Practice Address - Street 2:# 420
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-838-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF75442106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist