Provider Demographics
NPI:1447227087
Name:HARRISON, WILLIE CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:CHARLES
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINT HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6768
Mailing Address - Country:US
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:
Practice Address - Street 1:100 CLINT HILL BLVD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6771
Practice Address - Country:US
Practice Address - Phone:270-442-9461
Practice Address - Fax:270-441-0079
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006801A225100000X
OH009254225100000X
TX1311760225100000X
KY007650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000907335OtherANTHEM
OH0116838Medicaid
IN201265350Medicaid
000000907335OtherANTHEM