Provider Demographics
NPI:1770720864
Name:HARRIS, KRYSTAL (MOTR/L)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E LINDSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 E LINDSLEY RD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1152
Practice Address - Country:US
Practice Address - Phone:973-754-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00482100225X00000X, 314000000X
NY015966225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility