Healthcare Provider Details

I. General information

NPI: 1396947057
Provider Name (Legal Business Name): CHARISE MARIE VACCA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 REED RD SUITE C
COLUMBUS OH
43220-2581
US

IV. Provider business mailing address

52 WESTERVILLE SQ P.M.B. #201
WESTERVILLE OH
43081-2919
US

V. Phone/Fax

Practice location:
  • Phone: 614-388-5877
  • Fax: 614-388-5877
Mailing address:
  • Phone: 614-348-5848
  • Fax: 614-388-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5072
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: