Provider Demographics
NPI:1922534122
Name:CHARLES, DEBRA ANN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 S RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71602-4716
Mailing Address - Country:US
Mailing Address - Phone:870-872-1659
Mailing Address - Fax:
Practice Address - Street 1:3450 W 34TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5508
Practice Address - Country:US
Practice Address - Phone:870-534-7392
Practice Address - Fax:870-534-7297
Is Sole Proprietor?:No
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist