Provider Demographics
NPI:1104527498
Name:HARRISON, ANDRE L SR
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:L
Last Name:HARRISON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 EDELEN STATION PL
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-6966
Mailing Address - Country:US
Mailing Address - Phone:202-607-3092
Mailing Address - Fax:
Practice Address - Street 1:701 EDELEN STATION PL
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-6966
Practice Address - Country:US
Practice Address - Phone:202-607-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty