Provider Demographics
NPI:1972633170
Name:CHARLTON, LORI RENEE (PT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:RENEE
Last Name:CHARLTON
Suffix:
Gender:F
Credentials:PT
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 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2048
Practice Address - Fax:360-575-6749
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218607OtherLABOR & IND PHMG
WA0161310OtherLABOR & IND.
OR182763Medicaid
WA8943912OtherCRIME VICTIMS
WA8323891Medicaid
WAAB29683Medicare ID - Type Unspecified
OR182763Medicaid
WA8323891Medicaid