Provider Demographics
NPI:1902037674
Name:SPERISEN, CHARLOTTE ANNA (LMT)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:ANNA
Last Name:SPERISEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 6TH ST
Mailing Address - Street 2:307
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2471
Mailing Address - Country:US
Mailing Address - Phone:541-479-9481
Mailing Address - Fax:
Practice Address - Street 1:215 SE 6TH ST
Practice Address - Street 2:307
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2471
Practice Address - Country:US
Practice Address - Phone:541-479-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3435225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist