Provider Demographics
NPI:1649755604
Name:HARRISON, RANDICE R (MSPT)
Entity Type:Individual
Prefix:
First Name:RANDICE
Middle Name:R
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N ADELAIDE ST STE B
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2670
Mailing Address - Country:US
Mailing Address - Phone:810-354-8900
Mailing Address - Fax:810-354-8902
Practice Address - Street 1:102 N ADELAIDE ST STE B
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-354-8900
Practice Address - Fax:810-354-8902
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009582208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation