Provider Demographics
NPI:1265820005
Name:HARRIS, SAMUEL JR (COTA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8146
Mailing Address - Country:US
Mailing Address - Phone:405-921-4498
Mailing Address - Fax:
Practice Address - Street 1:910 E OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-8146
Practice Address - Country:US
Practice Address - Phone:405-921-4498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE879224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant