Basic Information
| Provider Information | |||||||||
| NPI: | 1578968475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLITTS | ||||||||
| FirstName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3108952353 | ||||||||
| Practice Location | |||||||||
| Address1: | 11133 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902323918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108952308 | ||||||||
| FaxNumber: | 3108952353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAS 01-101455 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.