MEDICARE: MR. ANDRE L HARRISON SR.

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	171M00000X	Case Manager/Care Coordinator
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1104527498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDRE L HARRISON SR.

Provider Business Mailing Address
First Line	:	701 EDELEN STATION PL
Second Line	:
City	:	LA PLATA
State	:	MD
Zip	:	20646-6966
Country	:	US
Telephone Number	:	202-607-3092
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 EDELEN STATION PL
Second Line	:
City	:	LA PLATA
State	:	MD
Zip	:	20646-6966
Country	:	US
Telephone Number	:	202-607-3092
Fax Number	:

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

Provider Enumeration Date	:	03/14/2023
Last Update Date	:	05/18/2023

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