Provider Demographics
NPI:1528671328
Name:LICKFOLD, CHARITY M (MFP, CPT, CNC)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:M
Last Name:LICKFOLD
Suffix:
Gender:F
Credentials:MFP, CPT, CNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-0555
Mailing Address - Country:US
Mailing Address - Phone:208-704-7632
Mailing Address - Fax:
Practice Address - Street 1:580 NE POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016-7470
Practice Address - Country:US
Practice Address - Phone:208-704-7632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise PhysiologistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty