Provider Demographics
NPI:1881936052
Name:DESAUTEL, CHARLENE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MARIE
Last Name:DESAUTEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FORTUYN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND COULEE
Mailing Address - State:WA
Mailing Address - Zip Code:99133-8718
Mailing Address - Country:US
Mailing Address - Phone:509-633-1911
Mailing Address - Fax:509-633-3644
Practice Address - Street 1:411 FORTUYN RD
Practice Address - Street 2:
Practice Address - City:GRAND COULEE
Practice Address - State:WA
Practice Address - Zip Code:99133-8718
Practice Address - Country:US
Practice Address - Phone:509-633-1911
Practice Address - Fax:509-633-3644
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G000301018Medicare PIN