Provider Demographics
NPI:1255717575
Name:CIVITELLO, CHARA (OCCUPATIONAL THERAPY)
Entity type:Individual
Prefix:
First Name:CHARA
Middle Name:
Last Name:CIVITELLO
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 CHASE COMMONS CT APT 207
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4640
Mailing Address - Country:US
Mailing Address - Phone:323-350-8395
Mailing Address - Fax:
Practice Address - Street 1:5804 CHASE COMMONS COURT APT 207
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015
Practice Address - Country:US
Practice Address - Phone:323-350-8395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006625225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation