Healthcare Provider Details

I. General information

NPI: 1023040599
Provider Name (Legal Business Name): CHARLES KODIMER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10927 DOWNEY AVE STE C
DOWNEY CA
90241-3739
US

IV. Provider business mailing address

41934 MAIN ST STE 203
TEMECULA CA
92590-2714
US

V. Phone/Fax

Practice location:
  • Phone: 562-861-6180
  • Fax: 951-694-0553
Mailing address:
  • Phone: 562-861-6180
  • Fax: 951-694-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 6629
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 6629
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 6318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: