Healthcare Provider Details

I. General information

NPI: 1902153646
Provider Name (Legal Business Name): CHARLES NWUFO MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14338 PARK AVE STE 200
VICTORVILLE CA
92392-2925
US

IV. Provider business mailing address

25808 SWEETLEAF ST
MORENO VALLEY CA
92553-4727
US

V. Phone/Fax

Practice location:
  • Phone: 760-354-9090
  • Fax:
Mailing address:
  • Phone: 951-662-5651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 70630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number3202
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: