Provider Demographics
NPI:1174730774
Name:RIDDLE, CHAREE' RENE' (PTA)
Entity type:Individual
Prefix:MISS
First Name:CHAREE'
Middle Name:RENE'
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 89J
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:OK
Mailing Address - Zip Code:74856-9734
Mailing Address - Country:US
Mailing Address - Phone:580-384-5486
Mailing Address - Fax:
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4610
Practice Address - Country:US
Practice Address - Phone:580-332-3349
Practice Address - Fax:580-421-1220
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKTA1190225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant