Provider Demographics
NPI:1336272020
Name:VERRAN, CLINT
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:VERRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8409 HALL RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5532
Mailing Address - Country:US
Mailing Address - Phone:586-323-8039
Mailing Address - Fax:586-323-8041
Practice Address - Street 1:8409 HALL RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5532
Practice Address - Country:US
Practice Address - Phone:586-323-8039
Practice Address - Fax:586-323-8041
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P15130Medicare PIN