Provider Demographics
NPI:1700042348
Name:BRACKETT, CLARENCE RYAN (MPT)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:RYAN
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 BOILING SPRINGS RD
Mailing Address - Street 2:SUITE 1600B
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4201
Mailing Address - Country:US
Mailing Address - Phone:864-582-0019
Mailing Address - Fax:
Practice Address - Street 1:1330 BOILING SPRINGS RD
Practice Address - Street 2:SUITE 1600B
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4201
Practice Address - Country:US
Practice Address - Phone:864-582-0019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3997OtherSTATE LICENSE NUMBER