Provider Demographics
NPI:1346380839
Name:HARRISON, ROBIN (PT)
Entity Type:Individual
Prefix:MS
First Name:ROBIN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:
Other - Last Name:GOODALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17465 S AVE B 1-4
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350
Mailing Address - Country:US
Mailing Address - Phone:928-627-1001
Mailing Address - Fax:
Practice Address - Street 1:1453 MAIN STREET N
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18352251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ418386OtherAHCCCS