Provider Demographics
NPI:1417295593
Name:OFFERMAN, CHARLIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:OFFERMAN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 WOODGLEN DR APT A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9298
Mailing Address - Country:US
Mailing Address - Phone:209-545-5685
Mailing Address - Fax:
Practice Address - Street 1:3521 WOODGLEN DR APT A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9298
Practice Address - Country:US
Practice Address - Phone:209-545-5685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA 1087172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17Medicare PIN