Basic Information
| Provider Information | |||||||||
| NPI: | 1699259507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DERRELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1518 N SERRANO AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900274874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235367817 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5650 JILLSON ST | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232014516 | ||||||||
| FaxNumber: | 3232150170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.