Provider Demographics
NPI:1265518344
Name:HARRISS, MICAH BRADLEY (PT)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:BRADLEY
Last Name:HARRISS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SABBATH RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5953
Mailing Address - Country:US
Mailing Address - Phone:337-856-9625
Mailing Address - Fax:
Practice Address - Street 1:3527 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:BOX 13
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5130
Practice Address - Country:US
Practice Address - Phone:337-857-6178
Practice Address - Fax:337-857-6592
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA004463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist