Provider Demographics
NPI:1376947325
Name:HARRIS, BRENDA (OT/L)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 HARRIS PRICE LN
Mailing Address - Street 2:
Mailing Address - City:SPRING CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37381-4473
Mailing Address - Country:US
Mailing Address - Phone:423-309-5059
Mailing Address - Fax:
Practice Address - Street 1:1204 FRYE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3052
Practice Address - Country:US
Practice Address - Phone:423-745-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN225X00000XMedicare UPIN