Provider Demographics
NPI:1427493501
Name:HARPER, MIA ANNETTE (ED SPECIALIST/MASTER)
Entity type:Individual
Prefix:MS
First Name:MIA
Middle Name:ANNETTE
Last Name:HARPER
Suffix:
Gender:F
Credentials:ED SPECIALIST/MASTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5984 LOCKLEAR WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1319
Mailing Address - Country:US
Mailing Address - Phone:313-320-1715
Mailing Address - Fax:
Practice Address - Street 1:5984 LOCKLEAR WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1319
Practice Address - Country:US
Practice Address - Phone:313-320-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA628955171M00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist