1295310407 NPI number — HARRIS INTEGRATIVE TRAINING & SUPERVISION, LLC

Table of content: CAITLIN CORIDDI PT, DPT (NPI 1407256704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295310407 NPI number — HARRIS INTEGRATIVE TRAINING & SUPERVISION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARRIS INTEGRATIVE TRAINING & SUPERVISION, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295310407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 SAINT FRANCIS CT APT 26
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40205-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-510-8082
Provider Business Mailing Address Fax Number:
703-991-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5413A BACKLICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22151-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-256-1600
Provider Business Practice Location Address Fax Number:
703-991-4878
Provider Enumeration Date:
03/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
THIEMANN
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
BILLING & CREDENTIALING MNAGER
Authorized Official Telephone Number:
502-510-8082

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 066770300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11752902 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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