Healthcare Provider Details

I. General information

NPI: 1275181463
Provider Name (Legal Business Name): COURTNEY HARRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 WAVERLY RD
HUNTINGTON WV
25704-1039
US

IV. Provider business mailing address

1401 CHESTNUT ST
KENOVA WV
25530-1235
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-3287
  • Fax:
Mailing address:
  • Phone: 304-453-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPSLP0817
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: