Provider Demographics
NPI:1750428934
Name:REEDY, CHARLENE R (MOTR/L)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:R
Last Name:REEDY
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8254 118TH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5027
Mailing Address - Country:US
Mailing Address - Phone:727-541-5304
Mailing Address - Fax:727-546-8527
Practice Address - Street 1:8254 118TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5027
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:727-546-8527
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10209225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL881802100Medicaid
FL8878021 00Medicaid