Basic Information
| Provider Information | |||||||||
| NPI: | 1972633170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLTON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986320302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142048 | ||||||||
| FaxNumber: | 3605756749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142048 | ||||||||
| FaxNumber: | 3605756749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00006513 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0218607 | 01 | WA | LABOR & IND PHMG | OTHER | 0161310 | 01 | WA | LABOR & IND. | OTHER | 182763 | 05 | OR | MEDICAID | 8943912 | 01 | WA | CRIME VICTIMS | OTHER | 8323891 | 05 | WA | MEDICAID |