Provider Demographics
NPI:1043633977
Name:MAITLAND, CHARLES (PTA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MAITLAND
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20325 N 51ST AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5674
Mailing Address - Country:US
Mailing Address - Phone:623-466-6350
Mailing Address - Fax:602-358-8698
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:623-466-6350
Practice Address - Fax:602-358-8698
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10731APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant