Provider Demographics
NPI:1417795717
Name:HARRIS, SELENA BRIANNA (OTD, MS, OTR/L)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:BRIANNA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:OTD, MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WEDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6528
Mailing Address - Country:US
Mailing Address - Phone:678-544-0695
Mailing Address - Fax:
Practice Address - Street 1:6035 PEACHTREE RD STE C120
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-3234
Practice Address - Country:US
Practice Address - Phone:678-514-3270
Practice Address - Fax:404-692-5581
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009220225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist