Provider Demographics
NPI:1679186795
Name:HARRISON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 4TH AVE E APT C2
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4972
Mailing Address - Country:US
Mailing Address - Phone:541-968-5769
Mailing Address - Fax:
Practice Address - Street 1:310 SUNNYVIEW LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3199
Practice Address - Country:US
Practice Address - Phone:541-968-5769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-LTD-LIC-111235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist