Healthcare Provider Details

I. General information

NPI: 1689127094
Provider Name (Legal Business Name): ELIJAH HARRIS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 UNIVERSITY DR SUITE A-6
AMHERST MA
01002-2473
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 413-366-5703
  • Fax: 413-992-2019
Mailing address:
  • Phone: 630-296-2223
  • Fax: 630-759-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21458
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: