Provider Demographics
NPI:1841275161
Name:RICHARDSON, CHARLES TIMOTHY (PT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:RICHARDSON
Suffix:
Gender:M
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:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34220
Mailing Address - Country:US
Mailing Address - Phone:941-729-1800
Mailing Address - Fax:941-722-7844
Practice Address - Street 1:506 4TH AVE W
Practice Address - Street 2:BLDG 4
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221
Practice Address - Country:US
Practice Address - Phone:941-729-1800
Practice Address - Fax:941-722-7844
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT08788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
650016193OtherRAILROAD MEDICARE
FLY900VOtherBLUE SHIELD
K0902Medicare ID - Type Unspecified