Provider Demographics
NPI:1124662069
Name:PETER, CHRISTLE ROSE (ODE IS K-12)
Entity type:Individual
Prefix:
First Name:CHRISTLE
Middle Name:ROSE
Last Name:PETER
Suffix:
Gender:F
Credentials:ODE IS K-12
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10521 WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:OH
Mailing Address - Zip Code:43466-9762
Mailing Address - Country:US
Mailing Address - Phone:419-806-1558
Mailing Address - Fax:
Practice Address - Street 1:3450 W CENTRAL AVE STE 126
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1421
Practice Address - Country:US
Practice Address - Phone:419-531-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3114193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist