1407264088 NPI number — MISTYANN HAZEL K HARRIS MA ED., BCBA

Table of content: MISTYANN HAZEL K HARRIS MA ED., BCBA (NPI 1407264088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407264088 NPI number — MISTYANN HAZEL K HARRIS MA ED., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
MISTYANN
Provider Middle Name:
HAZEL K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA ED., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIRK
Provider Other First Name:
MISTYANN
Provider Other Middle Name:
HAZEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407264088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2770 GREEN ASH LOOP
Provider Second Line Business Mailing Address:
APT 301
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22192-4153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-622-0762
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2770 GREEN ASH LOOP
Provider Second Line Business Practice Location Address:
APT 301
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-4153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-622-0762
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  0133000444 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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