=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073164612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE CHARLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2019
-----------------------------------------------------
Last Update Date | 09/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17707 STUDEBAKER RD STE 208
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-402-0677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12603 IBBETSON AVE
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90242-5049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-517-4326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------