Provider Demographics
NPI:1740954338
Name:HARRIS, CLIFFORD III (ATC)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:
Last Name:HARRIS
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 JULIET ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3448
Mailing Address - Country:US
Mailing Address - Phone:848-228-9295
Mailing Address - Fax:
Practice Address - Street 1:49 JULIET ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-3448
Practice Address - Country:US
Practice Address - Phone:848-228-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001677002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer