Basic Information
| Provider Information | |||||||||
| NPI: | 1336315514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 BRIMBAL AVE | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789272020 | ||||||||
| FaxNumber: | 9729224643 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 BRIMBAL AVE | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789272020 | ||||||||
| FaxNumber: | 9729224643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2709 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.