Provider Demographics
NPI:1760850655
Name:CLEVENGER, CHARLES MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5886 BROOKSTONE WALK NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8475
Mailing Address - Country:US
Mailing Address - Phone:770-499-9118
Mailing Address - Fax:770-792-8276
Practice Address - Street 1:144 BILL CARRUTH PKWY
Practice Address - Street 2:SUITE 4700
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3818
Practice Address - Country:US
Practice Address - Phone:678-453-5717
Practice Address - Fax:770-738-5476
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist