Healthcare Provider Details

I. General information

NPI: 1649190257
Provider Name (Legal Business Name): HARISADHAN PATRA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 STRAUB RD W APT 92
MANSFIELD OH
44904-1889
US

IV. Provider business mailing address

29 DUKE OF GLOUCESTER RD
BLOOMSBURG PA
17815-8399
US

V. Phone/Fax

Practice location:
  • Phone: 308-293-5728
  • Fax:
Mailing address:
  • Phone: 308-293-5728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP.07685
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: