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General NPI Number Information
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NPI Number | 1518104389
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Entity Type | Individual
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Provider Name | CHARLOTTE WIETHOFF-BRADLEY MFT
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Gender | Female
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Dates
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Enumeration Date | 01/14/2009
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Last Update Date | 02/16/2015
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Provider Practice Location Address
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Address Line | 1200 AVIATION BLVD STE 102
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City | REDONDO BEACH
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State | CA
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Zip | 90278-4064
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Country | US
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Telephone | 310-372-4245
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Fax | 310-379-6407
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Provider Business Mailing Address
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Address Line | 703 PIER AVE STE B196
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City | HERMOSA BEACH
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State | CA
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Zip | 90254-3949
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Country | US
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Telephone | 310-612-6299
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Fax | 310-379-6407
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 46587
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License Number State | CA
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