Provider Demographics
NPI:1972872794
Name:HARALSON, NATHAN LEE (ATC/L, CDA)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:LEE
Last Name:HARALSON
Suffix:
Gender:M
Credentials:ATC/L, CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 CLEMENT RD
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2451
Mailing Address - Country:US
Mailing Address - Phone:870-514-6224
Mailing Address - Fax:
Practice Address - Street 1:2860 I-55 SERVICE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-514-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT4302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer