Provider Demographics
NPI:1366063919
Name:RAMIREZ, CLARISSA A (ATC, LAT)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:A
Last Name:RAMIREZ
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 W BREAKWELL ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-3963
Mailing Address - Country:US
Mailing Address - Phone:202-485-9165
Mailing Address - Fax:
Practice Address - Street 1:99 SUPPORTING SERVICES RD., LOADING DOCK 2
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1015
Practice Address - Country:US
Practice Address - Phone:618-650-2935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32522255A2300X
IL096.0049952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS