MEDICARE: KEITH D HARRIS PT, CMTPT, DAC

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	225100000X	Physical Therapist	2305004493	VA
2	225100000X	Physical Therapist	PT38696	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	324581	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1477646768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH D HARRIS PT, CMTPT, DAC

Provider Business Mailing Address
First Line	:	2433 AUSTIN AVE
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32738-3003
Country	:	US
Telephone Number	:	757-334-9393
Fax Number	:

Provider Business Practice Location Address
First Line	:	2433 AUSTIN AVE STE B
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32738-3003
Country	:	US
Telephone Number	:	757-334-9393
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/16/2022

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