Provider Demographics
NPI:1659564789
Name:CO, CLARISSA C (PT)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:C
Last Name:CO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:STE G
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-218-4045
Practice Address - Fax:810-249-4230
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM23560296Medicare PIN