Provider Demographics
NPI:1851695118
Name:HARRIS, KIRA ELISE (PT)
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:ELISE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIRA
Other - Middle Name:ELISE
Other - Last Name:SHOEMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29822 S WIXOM RD
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-3434
Practice Address - Country:US
Practice Address - Phone:734-416-3900
Practice Address - Fax:734-416-3904
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750088Medicare PIN