Provider Demographics
NPI:1366578619
Name:WELDE, CHARLES WAYNE (MA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WAYNE
Last Name:WELDE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:
Other - Last Name:WELDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-1201
Mailing Address - Country:US
Mailing Address - Phone:626-962-2179
Mailing Address - Fax:
Practice Address - Street 1:3208 ROSEMEAD BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2830
Practice Address - Country:US
Practice Address - Phone:626-227-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF45796106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist