Provider Demographics
NPI:1720656960
Name:HARRISON, GRAYLING ELLIS JR
Entity Type:Individual
Prefix:
First Name:GRAYLING
Middle Name:ELLIS
Last Name:HARRISON
Suffix:JR
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 1:611 WATERWHEEL LN
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-2330
Mailing Address - Country:US
Mailing Address - Phone:443-469-1140
Mailing Address - Fax:
Practice Address - Street 1:611 WATERWHEEL LN
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2330
Practice Address - Country:US
Practice Address - Phone:443-469-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD28447OtherMARYLAND PT LICENSE #