Provider Demographics
NPI:1417540030
Name:HISERODT, CLARKE MAVERICK
Entity Type:Individual
Prefix:MR
First Name:CLARKE
Middle Name:MAVERICK
Last Name:HISERODT
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 1:1819 N BRIGHTON ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1005
Mailing Address - Country:US
Mailing Address - Phone:818-263-0790
Mailing Address - Fax:
Practice Address - Street 1:1819 N BRIGHTON ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1005
Practice Address - Country:US
Practice Address - Phone:818-263-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50686225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant