MEDICARE: CHARLES ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	110738	CA

General Provider Information

NPI Number	:	1790172013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES ANDERSON

Provider Business Mailing Address
First Line	:	825 WEBSTER ST STE D
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5522
Country	:	US
Telephone Number	:	707-386-8066
Fax Number	:	707-447-3205

Provider Business Practice Location Address
First Line	:	825 WEBSTER ST STE D
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5522
Country	:	US
Telephone Number	:	707-386-8066
Fax Number	:	707-673-2800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2015
Last Update Date	:	07/15/2020

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Directions to “ CHARLES ANDERSON ” Practice Location

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