Provider Demographics
NPI:1801774328
Name:POTTER, CHARISSE OLIVIA CASTINADO (PT, DPT)
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:OLIVIA CASTINADO
Last Name:POTTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CHARISSE
Other - Middle Name:OLIVIA
Other - Last Name:CASTINADO POTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:13021 S BILSTON LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2172
Mailing Address - Country:US
Mailing Address - Phone:720-971-4972
Mailing Address - Fax:
Practice Address - Street 1:11193 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8401
Practice Address - Country:US
Practice Address - Phone:801-415-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist