Provider Demographics
NPI:1457005076
Name:BULOSAN, CHARIS MAE T
Entity Type:Individual
Prefix:
First Name:CHARIS MAE
Middle Name:T
Last Name:BULOSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W 9TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3158
Mailing Address - Country:US
Mailing Address - Phone:562-774-3391
Mailing Address - Fax:
Practice Address - Street 1:624 W 9TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3158
Practice Address - Country:US
Practice Address - Phone:310-775-3843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health