Healthcare Provider Details

I. General information

NPI: 1205790953
Provider Name (Legal Business Name): QUA'TAVIS HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 BREEZEWOOD AVE STE 202
FAYETTEVILLE NC
28303-5283
US

IV. Provider business mailing address

2919 BREEZEWOOD AVE STE 202
FAYETTEVILLE NC
28303-5283
US

V. Phone/Fax

Practice location:
  • Phone: 910-674-3066
  • Fax: 910-401-1777
Mailing address:
  • Phone: 910-674-3066
  • Fax: 910-401-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: