Provider Demographics
NPI:1225660426
Name:NORTHCUTT, CHARLES WRIGHT IV (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WRIGHT
Last Name:NORTHCUTT
Suffix:IV
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:1716 RED OAK CIR.
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-4707
Mailing Address - Country:US
Mailing Address - Phone:903-335-6649
Mailing Address - Fax:
Practice Address - Street 1:1501 HOLIDAY DR.
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4707
Practice Address - Country:US
Practice Address - Phone:903-335-8727
Practice Address - Fax:903-335-8217
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2152450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant