Provider Demographics
NPI:1881807931
Name:MANN, CHARLENE (PTA)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:707 ELDRIDGE AVE E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-4032
Mailing Address - Country:US
Mailing Address - Phone:866-466-8989
Mailing Address - Fax:866-388-8107
Practice Address - Street 1:2915 S HAZEL ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5008
Practice Address - Country:US
Practice Address - Phone:870-535-0010
Practice Address - Fax:870-535-1116
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1385225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant