Provider Demographics
NPI:1073572277
Name:HARVEY, MARISA G (PT)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:G
Last Name:HARVEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 REGAL RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523-6281
Mailing Address - Country:US
Mailing Address - Phone:229-886-0880
Mailing Address - Fax:
Practice Address - Street 1:1204 HOSPITALITY AVE STE E
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6811
Practice Address - Country:US
Practice Address - Phone:912-996-2069
Practice Address - Fax:912-265-0041
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBPVMedicare ID - Type Unspecified