Healthcare Provider Details

I. General information

NPI: 1174352645
Provider Name (Legal Business Name): CHARLES JOSEPH FICKENTSHER JR. COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 TOWER CIR
SOMERSET KY
42503-3488
US

IV. Provider business mailing address

109 SPEEDWAY DR
SOMERSET KY
42503-1559
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-4578
  • Fax:
Mailing address:
  • Phone: 502-813-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number147777
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: