Provider Demographics
NPI:1710529763
Name:HARRIS, THERON
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:
Last Name:HARRIS
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 1:162 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4826
Mailing Address - Country:US
Mailing Address - Phone:914-819-7328
Mailing Address - Fax:
Practice Address - Street 1:162 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4826
Practice Address - Country:US
Practice Address - Phone:914-819-7328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant