Provider Demographics
NPI:1548429848
Name:NEAL, CHARLOTTE RENAE (LMT)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:RENAE
Last Name:NEAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 STEVENS ST
Mailing Address - Street 2:STE A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77026-6325
Mailing Address - Country:US
Mailing Address - Phone:832-640-9019
Mailing Address - Fax:
Practice Address - Street 1:1830 S KIRKWOOD RD
Practice Address - Street 2:STE 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5032
Practice Address - Country:US
Practice Address - Phone:832-640-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT044715171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX502617461Medicaid