=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023040599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES KODIMER PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 08/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10927 DOWNEY AVE STE C
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-3739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-861-6180
-----------------------------------------------------
Fax | 951-694-0553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41934 MAIN ST STE 203
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92590-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-861-6180
-----------------------------------------------------
Fax | 951-694-0553
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 6629
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY 6629
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 6318
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------