Provider Demographics
NPI:1477800266
Name:HARRISON, LEA
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:HARRISON
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 1:9936 AZALEA BLOOM WAY
Mailing Address - Street 2:APT. 208
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4626
Mailing Address - Country:US
Mailing Address - Phone:813-252-5521
Mailing Address - Fax:
Practice Address - Street 1:885 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6063
Practice Address - Country:US
Practice Address - Phone:813-436-5900
Practice Address - Fax:813-436-5901
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist