Healthcare Provider Details

I. General information

NPI: 1679437198
Provider Name (Legal Business Name): CHARLES VINCENT PANVINI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 THOMPSON AVE
GLENDALE CA
91201-1442
US

IV. Provider business mailing address

131 N EL MOLINO AVE STE 310
PASADENA CA
91101-1878
US

V. Phone/Fax

Practice location:
  • Phone: 818-245-5362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY34820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: