Provider Demographics
NPI:1619168531
Name:HARRIS, MARK E (LIC MASSAGE THERAPIS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LIC MASSAGE THERAPIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5616
Mailing Address - Country:US
Mailing Address - Phone:608-784-4471
Mailing Address - Fax:
Practice Address - Street 1:2400 DIAGONAL RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7619
Practice Address - Country:US
Practice Address - Phone:608-784-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2914 046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist