Provider Demographics
NPI:1194874073
Name:HARRIS, JUDITH ADELE (PT)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ADELE
Last Name:HARRIS
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 1:31700 VAN DYKE AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7949
Mailing Address - Country:US
Mailing Address - Phone:586-276-8001
Mailing Address - Fax:586-276-8002
Practice Address - Street 1:31700 VAN DYKE AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7949
Practice Address - Country:US
Practice Address - Phone:586-276-8001
Practice Address - Fax:586-276-8002
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI230195Medicare ID - Type UnspecifiedPROVIDER NUMBER