Healthcare Provider Details

I. General information

NPI: 1164637062
Provider Name (Legal Business Name): CHARLENE WILLAMS CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11726 SAN VICENTE BLVD SUITE 680
LOS ANGELES CA
90049
US

IV. Provider business mailing address

11726 SAN VICENTE BLVD SUITE 680
LOS ANGELES CA
90049
US

V. Phone/Fax

Practice location:
  • Phone: 310-442-9286
  • Fax:
Mailing address:
  • Phone: 310-442-9286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY15823
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY15823
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY15823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: