Provider Demographics
NPI:1528531878
Name:HARRELL, MICHAEL WILLIAM (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:HARRELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:WILLIAM
Other - Last Name:HARRELL
Other - Suffix:IX
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:1901 W SCREVEN ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-3913
Mailing Address - Country:US
Mailing Address - Phone:229-263-6100
Mailing Address - Fax:
Practice Address - Street 1:1901 W SCREVEN ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-3913
Practice Address - Country:US
Practice Address - Phone:229-263-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001156225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant