Provider Demographics
NPI:1154785178
Name:GRAHAM, CHARLES P (PTA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BLARNEY DRIVE, SUITE 202
Mailing Address - Street 2:COLUMBIA REHABILITATION CLINIC, INC.
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223
Mailing Address - Country:US
Mailing Address - Phone:803-736-4845
Mailing Address - Fax:803-736-8674
Practice Address - Street 1:115 BLARNEY DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223
Practice Address - Country:US
Practice Address - Phone:803-736-4845
Practice Address - Fax:803-736-8674
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3475225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant