Provider Demographics
NPI:1952480105
Name:HARRELL, ANDREW M SR
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:HARRELL
Suffix:SR
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 1:10333 124TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-6958
Mailing Address - Country:US
Mailing Address - Phone:386-362-6483
Mailing Address - Fax:386-362-2079
Practice Address - Street 1:11180 NE 38TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-2502
Practice Address - Country:US
Practice Address - Phone:386-792-6638
Practice Address - Fax:386-792-6401
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 3789101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional