Provider Demographics
NPI:1174352645
Name:FICKENTSHER, CHARLES JOSEPH JR (COTA/L)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:FICKENTSHER
Suffix:JR
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SPEEDWAY DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1559
Mailing Address - Country:US
Mailing Address - Phone:502-813-0027
Mailing Address - Fax:
Practice Address - Street 1:145 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3488
Practice Address - Country:US
Practice Address - Phone:606-679-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY147777224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant