Healthcare Provider Details

I. General information

NPI: 1417395906
Provider Name (Legal Business Name): TYEE CHARLTON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 BOTELHO DR STE 150
WALNUT CREEK CA
94596-5068
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 925-386-5657
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60698384
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310033
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2821
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: