Provider Demographics
NPI:1598011744
Name:O'MALLEY, CHARLES JOSEPH (DPT)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-2509
Mailing Address - Country:US
Mailing Address - Phone:570-368-8389
Mailing Address - Fax:570-368-8391
Practice Address - Street 1:1009 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2509
Practice Address - Country:US
Practice Address - Phone:570-368-8389
Practice Address - Fax:570-368-8391
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60296357225100000X
PAPT019822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist