Provider Demographics
NPI:1043836455
Name:HARLEY, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:HARLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 GRASSY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-6211
Mailing Address - Country:US
Mailing Address - Phone:352-434-8540
Mailing Address - Fax:352-609-2097
Practice Address - Street 1:5024 GRASSY KNOLL DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-6211
Practice Address - Country:US
Practice Address - Phone:352-434-8540
Practice Address - Fax:352-609-2097
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child