Provider Demographics
NPI:1548781131
Name:LIU, CHARLEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CHARLEY
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-2043
Mailing Address - Country:US
Mailing Address - Phone:847-501-0192
Mailing Address - Fax:
Practice Address - Street 1:37624 SE FURY ST
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-9680
Practice Address - Country:US
Practice Address - Phone:425-292-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13873-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist