Provider Demographics
NPI:1376518605
Name:HARRELL, RICHARD W (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:HARRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 PLANTATION RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-3837
Mailing Address - Country:US
Mailing Address - Phone:540-552-1904
Mailing Address - Fax:540-552-2201
Practice Address - Street 1:920 PLANTATION RD STE 104
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-3837
Practice Address - Country:US
Practice Address - Phone:540-552-1904
Practice Address - Fax:540-552-2201
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000553231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376518605Medicaid
VA009450912Medicaid
VA009691T45OtherPTAN
VAP00970290Medicare PIN
VAQ36965AMedicare PIN
VAS02441Medicare UPIN
VA1376518605Medicaid