Healthcare Provider Details

I. General information

NPI: 1720519788
Provider Name (Legal Business Name): MRS. CHARLOTTA P ZIMMERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 E SCHOOL ST
BONNE TERRE MO
63628-1724
US

IV. Provider business mailing address

136 E SCHOOL ST
BONNE TERRE MO
63628-1724
US

V. Phone/Fax

Practice location:
  • Phone: 636-232-5894
  • Fax: 314-845-3901
Mailing address:
  • Phone: 636-232-5894
  • Fax: 314-845-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-30663
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: