Provider Demographics
NPI:1629454178
Name:HARRISON, MARIA ALEXANDRA (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:ALEXANDRA
Last Name:HARRISON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BANKHEAD RD SW
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-7070
Mailing Address - Country:US
Mailing Address - Phone:662-322-0307
Mailing Address - Fax:
Practice Address - Street 1:1001 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2125
Practice Address - Country:US
Practice Address - Phone:662-323-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA3095224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant