Provider Demographics
NPI:1609394659
Name:HULL, BRENT (PT DPT)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:HULL
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4177 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7237
Mailing Address - Country:US
Mailing Address - Phone:231-421-5805
Mailing Address - Fax:231-421-5308
Practice Address - Street 1:4177 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-7237
Practice Address - Country:US
Practice Address - Phone:231-421-5805
Practice Address - Fax:231-421-8447
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750661542OtherPROVIDER