Provider Demographics
NPI:1730392762
Name:CASTLEBERG, CHARLES MONTGOMERY (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MONTGOMERY
Last Name:CASTLEBERG
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 1:925 LA COUNT RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313
Mailing Address - Country:US
Mailing Address - Phone:920-431-5588
Mailing Address - Fax:
Practice Address - Street 1:215 N. WEBSTER
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-431-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10345-24225100000X, 2251E1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36123900Medicaid