Provider Demographics
NPI:1265107874
Name:NUSSBAUM, CHARLEE (PTA)
Entity type:Individual
Prefix:
First Name:CHARLEE
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20740 E 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8741
Mailing Address - Country:US
Mailing Address - Phone:918-207-9233
Mailing Address - Fax:
Practice Address - Street 1:14002 E 21ST ST STE 650
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-1425
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3453225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant