Provider Demographics
NPI:1215649256
Name:FAULK, HARRISON RANDALL (LAT, ATC, PES)
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:RANDALL
Last Name:FAULK
Suffix:
Gender:M
Credentials:LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-1807
Mailing Address - Country:US
Mailing Address - Phone:406-268-6100
Mailing Address - Fax:
Practice Address - Street 1:228 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1807
Practice Address - Country:US
Practice Address - Phone:406-268-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTATR-LAT-LIC-26852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer