Provider Demographics
NPI:1730200940
Name:HARRIS, KEVIN RAY (BS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RAY
Last Name:HARRIS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5747 LAUREL CANYON BLVD
Mailing Address - Street 2:33
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1217
Mailing Address - Country:US
Mailing Address - Phone:818-769-2816
Mailing Address - Fax:
Practice Address - Street 1:2055 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1324
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner