MEDICARE: MRS. CRYSTAL M. HARRIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225800000X	Recreation Therapist	225800000X	MI
2	164W00000X	Licensed Practical Nurse	4703117523	MI

General Provider Information

NPI Number	:	1619286127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL M. HARRIS

Provider Business Mailing Address
First Line	:	26630 SUMPTER RD
Second Line	:
City	:	SUMPTER TWP
State	:	MI
Zip	:	48111-8805
Country	:	US
Telephone Number	:	313-422-5551
Fax Number	:

Provider Business Practice Location Address
First Line	:	26630 SUMPTER RD
Second Line	:
City	:	SUMPTER TWP
State	:	MI
Zip	:	48111
Country	:	US
Telephone Number	:	313-422-5551
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2010
Last Update Date	:	08/01/2018

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