Provider Demographics
NPI:1962947804
Name:CEARLOCK, CHARLOTTE
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:CEARLOCK
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 1:907 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4153
Mailing Address - Country:US
Mailing Address - Phone:618-339-3700
Mailing Address - Fax:
Practice Address - Street 1:907 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4153
Practice Address - Country:US
Practice Address - Phone:618-339-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist