Provider Demographics
NPI:1376636308
Name:HARRIS, CHARLIE M (RPT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLIE
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 E FERNROCK ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2539
Mailing Address - Country:US
Mailing Address - Phone:310-639-1079
Mailing Address - Fax:310-635-6407
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6691
Practice Address - Fax:323-563-6378
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist