Provider Demographics
NPI:1477703478
Name:WITCHER, CHARLES STACY (LPTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:STACY
Last Name:WITCHER
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 N 74TH ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-6222
Mailing Address - Country:US
Mailing Address - Phone:870-215-2070
Mailing Address - Fax:
Practice Address - Street 1:417 SW THIRD ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-2310
Practice Address - Country:US
Practice Address - Phone:870-886-2443
Practice Address - Fax:870-886-3289
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1351225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant