Provider Demographics
NPI:1003271453
Name:GILLETTE, CHARLES JOHN (MS, ATC, CSFA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOHN
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:MS, ATC, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 HERMAN CT
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2421
Mailing Address - Country:US
Mailing Address - Phone:608-797-8779
Mailing Address - Fax:
Practice Address - Street 1:605 HERMAN CT
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2421
Practice Address - Country:US
Practice Address - Phone:608-797-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0063062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer