Provider Demographics
NPI:1588399984
Name:CHARBONEAU, CASSIE LYNNE
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:LYNNE
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 M 212 HWY
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-8234
Mailing Address - Country:US
Mailing Address - Phone:231-445-1191
Mailing Address - Fax:
Practice Address - Street 1:401 W ELM ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1622
Practice Address - Country:US
Practice Address - Phone:231-445-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007956225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty