Provider Demographics
NPI:1104986496
Name:HARRIS, MARK (LMT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 CHANEL DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3812
Mailing Address - Country:US
Mailing Address - Phone:631-281-2128
Mailing Address - Fax:
Practice Address - Street 1:140 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2004
Practice Address - Country:US
Practice Address - Phone:631-254-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019351225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist