Healthcare Provider Details

I. General information

NPI: 1720390347
Provider Name (Legal Business Name): CHARLA-JO OLORENSHAW SPRADLIN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHARLA-JO OLORENSHAW PT

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26453 N OLD HIGHWAY 95
ATHOL ID
83801-7076
US

IV. Provider business mailing address

26453 N OLD HIGHWAY 95
ATHOL ID
83801-7076
US

V. Phone/Fax

Practice location:
  • Phone: 208-597-4595
  • Fax:
Mailing address:
  • Phone: 208-597-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-425
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: