Provider Demographics
NPI:1720519788
Name:ZIMMERMAN, CHARLOTTA P
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTA
Middle Name:P
Last Name:ZIMMERMAN
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 1:136 E SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1724
Mailing Address - Country:US
Mailing Address - Phone:636-232-5894
Mailing Address - Fax:314-845-3901
Practice Address - Street 1:136 E SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1724
Practice Address - Country:US
Practice Address - Phone:636-232-5894
Practice Address - Fax:314-845-3901
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-17-30663106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992256945Medicaid