Provider Demographics
NPI:1275317562
Name:CHARLOTTE MYOFUNCTIONAL THERAPY LLC
Entity Type:Organization
Organization Name:CHARLOTTE MYOFUNCTIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MYOFUNCTIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-738-6898
Mailing Address - Street 1:309 MINDEN LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-9141
Mailing Address - Country:US
Mailing Address - Phone:607-738-6898
Mailing Address - Fax:
Practice Address - Street 1:1308 THE PLZ APT F
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-3679
Practice Address - Country:US
Practice Address - Phone:704-891-3262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty