Provider Demographics
NPI:1558790402
Name:VANCLEVE, CHARITY
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:
Last Name:VANCLEVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 RADFORD RD STE 4
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2272
Mailing Address - Country:US
Mailing Address - Phone:563-587-8317
Mailing Address - Fax:563-587-8319
Practice Address - Street 1:1880 RADFORD RD STE 4
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2272
Practice Address - Country:US
Practice Address - Phone:563-587-8317
Practice Address - Fax:563-587-8319
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist