Provider Demographics
NPI:1881366938
Name:MASUMOTO, HARLEY RENEE
Entity type:Individual
Prefix:
First Name:HARLEY
Middle Name:RENEE
Last Name:MASUMOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HARLEY
Other - Middle Name:RENEE
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20500 STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4067
Mailing Address - Country:US
Mailing Address - Phone:586-563-5234
Mailing Address - Fax:
Practice Address - Street 1:33464 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6314
Practice Address - Country:US
Practice Address - Phone:586-275-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician