Provider Demographics
NPI:1922409002
Name:HARRELL, VICTOR D (LMSW, PA-C)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:D
Last Name:HARRELL
Suffix:
Gender:M
Credentials:LMSW, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17566 SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2645
Mailing Address - Country:US
Mailing Address - Phone:313-966-2800
Mailing Address - Fax:313-966-7797
Practice Address - Street 1:6001 W OUTER DR STE 207
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2626
Practice Address - Country:US
Practice Address - Phone:313-966-2800
Practice Address - Fax:313-966-7797
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010907901041C0700X
MI5601009949363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical