Provider Demographics
NPI:1427018449
Name:HARLESS, EDWIN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:HARLESS
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 1:3531 STANCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8522
Mailing Address - Country:US
Mailing Address - Phone:336-766-0778
Mailing Address - Fax:
Practice Address - Street 1:190 KIMEL PARK RD
Practice Address - Street 2:VA OUTPATIENT CLINIC
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3296
Practice Address - Fax:336-760-5496
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1428231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist