Healthcare Provider Details

I. General information

NPI: 1518870146
Provider Name (Legal Business Name): CHARLENE BAILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SHOREHAM PL STE 100
SAN DIEGO CA
92122-5904
US

IV. Provider business mailing address

4653 CARMEL MOUNTAIN RD STE 308 PMB 1009
SAN DIEGO CA
92130-6650
US

V. Phone/Fax

Practice location:
  • Phone: 619-630-7793
  • Fax:
Mailing address:
  • Phone: 858-252-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165328
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: