Provider Demographics
NPI:1295705440
Name:HARR, PHYLLIS (RPT CLT LANA)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:HARR
Suffix:
Gender:F
Credentials:RPT CLT LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 DOUGLAS BLVD
Mailing Address - Street 2:#306-280
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5936
Mailing Address - Country:US
Mailing Address - Phone:916-791-8121
Mailing Address - Fax:916-791-8121
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-784-5734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT99710Medicare ID - Type Unspecified
CAP562930Medicare UPIN