Provider Demographics
NPI:1013932433
Name:HARRISON, BETH BLAKE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:BLAKE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 CALLCOTT WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-4105
Mailing Address - Country:US
Mailing Address - Phone:703-678-5692
Mailing Address - Fax:
Practice Address - Street 1:5708 CALLCOTT WAY UNIT A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-4105
Practice Address - Country:US
Practice Address - Phone:703-678-5692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist