Provider Demographics
NPI:1477823573
Name:SIPE, BRENT (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:SIPE
Suffix:
Gender:M
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 1:22784 HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-6425
Mailing Address - Country:US
Mailing Address - Phone:281-577-8630
Mailing Address - Fax:
Practice Address - Street 1:22784 HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-6425
Practice Address - Country:US
Practice Address - Phone:281-577-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT12172255A2300X
0694026912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer