Provider Demographics
NPI:1780225169
Name:BARAIAC, CLARISSA MARIE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:MARIE
Last Name:BARAIAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:MARIE
Other - Last Name:BARAIAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26366 WOLVERINE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3714
Mailing Address - Country:US
Mailing Address - Phone:248-434-7196
Mailing Address - Fax:
Practice Address - Street 1:26366 WOLVERINE ST
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3714
Practice Address - Country:US
Practice Address - Phone:248-434-7196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1689148146N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic