Provider Demographics
NPI:1497162614
Name:HARRISON, BRIAN MARK (MS, OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MARK
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:O-208 HERON DR NW APT 306
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-1081
Mailing Address - Country:US
Mailing Address - Phone:616-799-2468
Mailing Address - Fax:616-942-5695
Practice Address - Street 1:4280 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8301
Practice Address - Country:US
Practice Address - Phone:616-942-5570
Practice Address - Fax:616-942-5695
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008337225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist