Provider Demographics
NPI:1629716840
Name:HARRISON, MAKYLA DANNIELL (PTA)
Entity Type:Individual
Prefix:
First Name:MAKYLA
Middle Name:DANNIELL
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MAKYLA
Other - Middle Name:DANNIELL
Other - Last Name:SPRINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:11114 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-2409
Mailing Address - Country:US
Mailing Address - Phone:319-651-5295
Mailing Address - Fax:
Practice Address - Street 1:10800 TEMPLE TER
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4736
Practice Address - Country:US
Practice Address - Phone:727-547-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30629225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant