Provider Demographics
NPI:1730348772
Name:HARNEY, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:SANTA CLAUS
Mailing Address - State:IN
Mailing Address - Zip Code:47579-0167
Mailing Address - Country:US
Mailing Address - Phone:812-686-2476
Mailing Address - Fax:
Practice Address - Street 1:17049 N STATE ROAD 245
Practice Address - Street 2:
Practice Address - City:DALE
Practice Address - State:IN
Practice Address - Zip Code:47523
Practice Address - Country:US
Practice Address - Phone:812-686-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200863260Medicaid