Provider Demographics
NPI:1164707683
Name:DESTRA, CHARLES JOHN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JOHN
Last Name:DESTRA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 PECAN DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2817
Mailing Address - Country:US
Mailing Address - Phone:215-961-2528
Mailing Address - Fax:
Practice Address - Street 1:1616 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-938-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC005061L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist