Provider Demographics
NPI:1265883680
Name:CHARLES, BREANNA J (LMFT)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:J
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SAN PEDRO HEALING
Other - Middle Name:
Other - Last Name:ARTS MEDICAL CLINIC INC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1366 W 7TH ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:310-547-2197
Mailing Address - Fax:310-547-9532
Practice Address - Street 1:1366 W 7TH ST STE 4B
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:310-547-9532
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT86500106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT86500OtherLMFT