Basic Information
| Provider Information | |||||||||
| NPI: | 1992251839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HABERMANN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12020 PACIFIC ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681543507 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | 400 EAST THIRD STREET | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.