Provider Demographics
NPI:1104179514
Name:HARRISON, LOIS MYRLEEN (MT)
Entity Type:Individual
Prefix:MRS
First Name:LOIS
Middle Name:MYRLEEN
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-2098
Mailing Address - Country:US
Mailing Address - Phone:239-821-5695
Mailing Address - Fax:
Practice Address - Street 1:880 5TH ST NW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34120-2098
Practice Address - Country:US
Practice Address - Phone:239-821-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63569225700000X
PAMSG 002567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist