Provider Demographics
NPI:1477225126
Name:CALLAGHAN, CHARLES BRENDAN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRENDAN
Last Name:CALLAGHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3722
Mailing Address - Country:US
Mailing Address - Phone:954-669-0032
Mailing Address - Fax:
Practice Address - Street 1:2301 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-3722
Practice Address - Country:US
Practice Address - Phone:954-669-0032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24150225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant