Provider Demographics
NPI:1174898225
Name:HARRIS, GENIQUA M (ATC)
Entity type:Individual
Prefix:MS
First Name:GENIQUA
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 BURNETT AVE S
Mailing Address - Street 2:APT B304
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2107
Mailing Address - Country:US
Mailing Address - Phone:206-818-5578
Mailing Address - Fax:
Practice Address - Street 1:232 BURNETT AVE S
Practice Address - Street 2:APT B304
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2107
Practice Address - Country:US
Practice Address - Phone:206-818-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer