Provider Demographics
NPI:1770708844
Name:MIKE, CHARLES E
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:MIKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10206 CAVALIER XING
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-5363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6849 PEACHTREE DUNWOODY RD NE STE 102
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1610
Practice Address - Country:US
Practice Address - Phone:678-587-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000896224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant