Healthcare Provider Details

I. General information

NPI: 1134449788
Provider Name (Legal Business Name): CHARLES EDWARD DELEEUW M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2010
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

IV. Provider business mailing address

262 N LOS ROBLES AVE APT. 327
PASADENA CA
91101-1533
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-2794
  • Fax:
Mailing address:
  • Phone: 616-204-2413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: