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General NPI Number Information
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NPI Number | 1114485323
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Entity Type | Individual
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Provider Name | CHARLES WILLIAM CROOK
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Gender | Male
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Dates
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Enumeration Date | 03/06/2019
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Last Update Date | 11/16/2023
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Provider Practice Location Address
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Address Line | 3400 PACIFIC AVE APT 208
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City | MARINA DEL REY
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State | CA
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Zip | 90292-7815
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Country | US
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Telephone | 310-428-8787
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 PACIFIC AVE APT 208
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City | MARINA DEL REY
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State | CA
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Zip | 90292-7815
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Country | US
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Telephone | 310-428-8787
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 15487
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 30680
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License Number State | CA
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