Provider Demographics
NPI:1710120613
Name:HARLESS, MICHAEL DALE
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DALE
Last Name:HARLESS
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 1:9133 BARRINGTON LN
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-5102
Mailing Address - Country:US
Mailing Address - Phone:727-967-5467
Mailing Address - Fax:
Practice Address - Street 1:11836 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669
Practice Address - Country:US
Practice Address - Phone:727-379-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692668179Medicaid