Healthcare Provider Details

I. General information

NPI: 1003028515
Provider Name (Legal Business Name): CHARLENE NORQUIST MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 41ST AVE STE 100
CAPITOLA CA
95010-3934
US

IV. Provider business mailing address

1350 41ST AVE STE 100
CAPITOLA CA
95010-3934
US

V. Phone/Fax

Practice location:
  • Phone: 831-706-2085
  • Fax:
Mailing address:
  • Phone: 831-706-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT 25785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: