Provider Demographics
NPI:1659899128
Name:ABOUSSLEMAN, BRADY GEORGE (AT, ATC)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:GEORGE
Last Name:ABOUSSLEMAN
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-1501
Mailing Address - Country:US
Mailing Address - Phone:906-250-5630
Mailing Address - Fax:
Practice Address - Street 1:841 W WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4149
Practice Address - Country:US
Practice Address - Phone:906-250-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer