Provider Demographics
NPI:1871803692
Name:ETTINOFFE, CHARISSA
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ETTINOFFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11405 SUMMIT BAY DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-2558
Mailing Address - Country:US
Mailing Address - Phone:832-865-0059
Mailing Address - Fax:
Practice Address - Street 1:11405 SUMMIT BAY DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2558
Practice Address - Country:US
Practice Address - Phone:832-865-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110333225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist