Provider Demographics
NPI:1699821587
Name:ANDERSON, CHARLENE M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0907
Mailing Address - Country:US
Mailing Address - Phone:417-625-5290
Mailing Address - Fax:417-625-5297
Practice Address - Street 1:1717 E 15TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0907
Practice Address - Country:US
Practice Address - Phone:417-625-5290
Practice Address - Fax:417-625-5297
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002992225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO002992OtherMO BOARD OF OT