Provider Demographics
NPI:1629006721
Name:HARRISON, MARY T (MSN, RN, CS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:T
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MSN, RN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3821
Mailing Address - Country:US
Mailing Address - Phone:440-233-7232
Mailing Address - Fax:440-233-9070
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:440-233-9070
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS-06845364SP0809X
OHCOA06845NS163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ15883Medicare UPIN
OHHANS02815Medicare ID - Type Unspecified