Provider Demographics
NPI:1356864896
Name:MAYALL, CHARMAINE BERNARDINO (DPT)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:BERNARDINO
Last Name:MAYALL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CHARMAINE
Other - Middle Name:DOMAGAS
Other - Last Name:BERNARDINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:910 OAKWOOD DR APT 177
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1372
Mailing Address - Country:US
Mailing Address - Phone:352-391-7933
Mailing Address - Fax:
Practice Address - Street 1:910 OAKWOOD DR APT 177
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1372
Practice Address - Country:US
Practice Address - Phone:352-391-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00Other00