Provider Demographics
NPI:1356472955
Name:HARRALSON, PATRICIA L
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:HARRALSON
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 1:505 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2608
Mailing Address - Country:US
Mailing Address - Phone:765-662-3971
Mailing Address - Fax:
Practice Address - Street 1:505 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2608
Practice Address - Country:US
Practice Address - Phone:765-662-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01062486A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64300759Medicaid
KY64300759Medicaid
1568601Medicare ID - Type Unspecified