Individual
MR. CLARKE MAVERICK HISERODT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1819 N BRIGHTON ST, BURBANK, CA 91506-1005
(818) 263-0790
Mailing address
1819 N BRIGHTON ST, BURBANK, CA 91506-1005
(818) 263-0790
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
50686
CA
Other
Enumeration date
02/15/2021
Last updated
06/24/2021
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