Provider Demographics
NPI:1104928266
Name:HARLAND, RENATA ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:RENATA
Middle Name:ELLEN
Last Name:HARLAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 PEACH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-2120
Mailing Address - Country:US
Mailing Address - Phone:814-440-7909
Mailing Address - Fax:814-240-6886
Practice Address - Street 1:1611 PEACH ST STE 105
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2120
Practice Address - Country:US
Practice Address - Phone:814-440-7909
Practice Address - Fax:814-240-6886
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016407103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000663Medicaid
NC2821766Medicare ID - Type Unspecified