Provider Demographics
NPI:1902180680
Name:CHARLEVILLE, STEPHANIE RACHEL (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RACHEL
Last Name:CHARLEVILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 RIVER GREEN PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8336
Mailing Address - Country:US
Mailing Address - Phone:770-988-2779
Mailing Address - Fax:678-730-0229
Practice Address - Street 1:5529 GLENRIDGE PARK NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1792
Practice Address - Country:US
Practice Address - Phone:678-848-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist