Provider Demographics
NPI:1972384675
Name:HARDER, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:HARDER
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 1:4638 RIVERSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-6157
Mailing Address - Country:US
Mailing Address - Phone:832-419-2729
Mailing Address - Fax:
Practice Address - Street 1:2743 SMITH RANCH RD
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-5204
Practice Address - Country:US
Practice Address - Phone:832-598-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22-250934106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician