Provider Demographics
NPI:1295268886
Name:WATTENBERG, CHARLES (MFT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WATTENBERG
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 REDWOOD WAY
Mailing Address - Street 2:SUITE 223
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1107
Mailing Address - Country:US
Mailing Address - Phone:707-762-2998
Mailing Address - Fax:
Practice Address - Street 1:1301 REDWOOD WAY
Practice Address - Street 2:SUITE 223
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1107
Practice Address - Country:US
Practice Address - Phone:707-762-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMX18124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist