Provider Demographics
NPI:1457097503
Name:CANTRELL, CHRISTOPHER DALE (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DALE
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1233
Mailing Address - Country:US
Mailing Address - Phone:937-417-9008
Mailing Address - Fax:
Practice Address - Street 1:750 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1312
Practice Address - Country:US
Practice Address - Phone:937-547-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013143208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation