Provider Demographics
NPI:1790088920
Name:HARRISON, ROBERT MICHAEL (MS,ATC,LAT,LMT,PES)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MS,ATC,LAT,LMT,PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 MERRILL RD
Mailing Address - Street 2:APT 1108
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-3774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3321
Practice Address - Country:US
Practice Address - Phone:904-256-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA55420225700000X
FLAL27192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist