Provider Demographics
NPI:1417138058
Name:LOFTERS, CHARLENE GRACE (MPT, DPT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:GRACE
Last Name:LOFTERS
Suffix:
Gender:F
Credentials:MPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:770-792-5284
Mailing Address - Fax:770-792-1513
Practice Address - Street 1:815 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-792-5284
Practice Address - Fax:770-792-1513
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist