Provider Demographics
NPI:1881751550
Name:TACY, CHARLOTTE JUNE (OT)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:JUNE
Last Name:TACY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 FLOYD AVE
Mailing Address - Street 2:APT. 216
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8750
Mailing Address - Country:US
Mailing Address - Phone:209-484-2396
Mailing Address - Fax:
Practice Address - Street 1:2929 FLOYD AVE
Practice Address - Street 2:APT. 216
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-8750
Practice Address - Country:US
Practice Address - Phone:209-484-2396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2711225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist