Provider Demographics
NPI:1588318620
Name:HARLOW, AUDRE TARA (LMT)
Entity type:Individual
Prefix:
First Name:AUDRE
Middle Name:TARA
Last Name:HARLOW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64-730 WAIKELEHUA PL
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8375
Mailing Address - Country:US
Mailing Address - Phone:808-895-0139
Mailing Address - Fax:
Practice Address - Street 1:65-1238 MAMALAHOA HWY BLDG C20A
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8432
Practice Address - Country:US
Practice Address - Phone:808-895-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist