Provider Demographics
NPI:1003672825
Name:MCCOTTER, CHARISSE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:
Last Name:MCCOTTER
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 1:1204 MAIN ST # 829
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3787
Mailing Address - Country:US
Mailing Address - Phone:203-928-9155
Mailing Address - Fax:
Practice Address - Street 1:191 DELAURO DR APT M
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6013
Practice Address - Country:US
Practice Address - Phone:203-928-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20-0106Y21246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy