Provider Demographics
NPI:1134941487
Name:HARRIS, ALISA JOVAN (LICENSED MASSAGE THE)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:JOVAN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 AUBURN AVE NE # 22
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1940
Mailing Address - Country:US
Mailing Address - Phone:404-890-0713
Mailing Address - Fax:
Practice Address - Street 1:659 AUBURN AVE NE # 22
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1940
Practice Address - Country:US
Practice Address - Phone:404-890-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010377225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist