Provider Demographics
NPI:1720390347
Name:SPRADLIN, CHARLA-JO OLORENSHAW (PT)
Entity Type:Individual
Prefix:
First Name:CHARLA-JO
Middle Name:OLORENSHAW
Last Name:SPRADLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHARLA-JO
Other - Middle Name:
Other - Last Name:OLORENSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:26453 N OLD HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-7076
Mailing Address - Country:US
Mailing Address - Phone:208-597-4595
Mailing Address - Fax:
Practice Address - Street 1:26453 N OLD HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-7076
Practice Address - Country:US
Practice Address - Phone:208-597-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist