Provider Demographics
NPI:1376636449
Name:QUENNEVILLE, CHARLENE M (ATC)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:M
Last Name:QUENNEVILLE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33947 KIRBY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-5251
Mailing Address - Country:US
Mailing Address - Phone:248-477-9185
Mailing Address - Fax:
Practice Address - Street 1:33947 KIRBY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5251
Practice Address - Country:US
Practice Address - Phone:248-477-9185
Practice Address - Fax:
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
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer