Provider Demographics
NPI:1083115497
Name:LONGHITANO, CHAROLETTE ROSE
Entity Type:Individual
Prefix:
First Name:CHAROLETTE
Middle Name:ROSE
Last Name:LONGHITANO
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 1:12395 MCCRACKEN RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2967
Mailing Address - Country:US
Mailing Address - Phone:440-969-4374
Mailing Address - Fax:
Practice Address - Street 1:11249 WOOD DUCK AVE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-2349
Practice Address - Country:US
Practice Address - Phone:440-969-4374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY$$$$$$$$$Medicaid
OH$$$$$$$$$Medicaid