Provider Demographics
NPI:1689493702
Name:MICHAEL HAILU, CLEMENTINE (MPT)
Entity type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:
Last Name:MICHAEL HAILU
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 OAKWICK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-7005
Mailing Address - Country:US
Mailing Address - Phone:281-416-6136
Mailing Address - Fax:
Practice Address - Street 1:3907 OAKWICK FOREST DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-7005
Practice Address - Country:US
Practice Address - Phone:281-416-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1391974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist