Provider Demographics
NPI:1700102712
Name:WEDGEWORTH, CHARLEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLEE
Middle Name:
Last Name:WEDGEWORTH
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 1:7247 LIVE OAK WAY
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-8024
Mailing Address - Country:US
Mailing Address - Phone:228-452-3245
Mailing Address - Fax:228-452-3245
Practice Address - Street 1:174 CLIFF MITCHELL RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-7982
Practice Address - Country:US
Practice Address - Phone:601-798-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist