Healthcare Provider Details

I. General information

NPI: 1730499765
Provider Name (Legal Business Name): CHARLES ROBERTS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 SAINT PAUL ST
ROCHESTER NY
14605-1709
US

IV. Provider business mailing address

85 REDDICK LN
ROCHESTER NY
14624-1959
US

V. Phone/Fax

Practice location:
  • Phone: 585-324-9956
  • Fax:
Mailing address:
  • Phone: 585-594-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number007385-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: