MEDICARE: CHARLA JENA CHILDERS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	1933	AL

General Provider Information

NPI Number	:	1790809556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLA JENA CHILDERS OTRL

Provider Business Mailing Address
First Line	:	118 ADRIS PLACE
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-1997
Country	:	US
Telephone Number	:	334-677-6360
Fax Number	:	334-678-6540

Provider Business Practice Location Address
First Line	:	118 ADRIS PLACE
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-1997
Country	:	US
Telephone Number	:	334-677-6360
Fax Number	:	334-678-6540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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Directions to “ CHARLA JENA CHILDERS OTRL” Practice Location

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