Provider Demographics
NPI:1174098115
Name:HARBISON, CARL RAYE JR
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:RAYE
Last Name:HARBISON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MO
Mailing Address - Zip Code:63650-9123
Mailing Address - Country:US
Mailing Address - Phone:573-915-6531
Mailing Address - Fax:
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health