Provider Demographics
NPI:1538663240
Name:CHARLOCK, TERRI ALEXANDER
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:ALEXANDER
Last Name:CHARLOCK
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 1:5314 BAREFOOT PATH
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4809
Mailing Address - Country:US
Mailing Address - Phone:407-731-4780
Mailing Address - Fax:
Practice Address - Street 1:5314 BAREFOOT PATH
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746
Practice Address - Country:US
Practice Address - Phone:407-731-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer