Provider Demographics
NPI:1447830021
Name:HARRISON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARRISON
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 1:301 HARBOUR PLACE DR UNIT 1910
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6807
Mailing Address - Country:US
Mailing Address - Phone:201-264-0103
Mailing Address - Fax:
Practice Address - Street 1:3041 BERKS WAY STE 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6777
Practice Address - Country:US
Practice Address - Phone:919-488-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8757235Z00000X
NC30001907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447830021OtherSPEECH LANGUAGE PATHOLOGIST
FL1447830021OtherSPEECH LANGUAGE PATHOLOGIST
FLSA17923OtherFLORIDA DEPARTMENT OF HEALTH