Provider Demographics
NPI:1124538533
Name:CHARLES, LYNNE CROCKETT (PT)
Entity Type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:CROCKETT
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:FRANCES
Other - Middle Name:LYNNE
Other - Last Name:CROCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1932 GULLWING DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5389
Mailing Address - Country:US
Mailing Address - Phone:757-509-8994
Mailing Address - Fax:
Practice Address - Street 1:810 E RALPH HALL PKWY
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6878
Practice Address - Country:US
Practice Address - Phone:972-722-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1286062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist