Provider Demographics
NPI:1669727871
Name:PEARISO, BRODERICK EARL (PTA)
Entity type:Individual
Prefix:
First Name:BRODERICK
Middle Name:EARL
Last Name:PEARISO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 E JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-8552
Mailing Address - Country:US
Mailing Address - Phone:517-332-7246
Mailing Address - Fax:517-332-1474
Practice Address - Street 1:3370 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8552
Practice Address - Country:US
Practice Address - Phone:517-332-7246
Practice Address - Fax:517-332-1474
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001428225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant