Provider Demographics
NPI:1720596224
Name:FEWTRELL, CHARLEEN (LMT)
Entity Type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:FEWTRELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65578 PARKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-9779
Mailing Address - Country:US
Mailing Address - Phone:219-380-6280
Mailing Address - Fax:
Practice Address - Street 1:8089 STADIUM DR # DT
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6270
Practice Address - Country:US
Practice Address - Phone:269-888-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007887225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist