Provider Demographics
NPI:1114597010
Name:FESKO, CHARISSE ANNE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:ANNE
Last Name:FESKO
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 1:210 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1774
Mailing Address - Country:US
Mailing Address - Phone:248-643-8900
Mailing Address - Fax:248-740-3505
Practice Address - Street 1:210 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1774
Practice Address - Country:US
Practice Address - Phone:248-643-8900
Practice Address - Fax:248-740-3505
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist