Provider Demographics
NPI:1295750636
Name:HARRISON, JOHN ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PHD
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 31001-4110
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4110
Mailing Address - Country:US
Mailing Address - Phone:406-327-3330
Mailing Address - Fax:406-327-2399
Practice Address - Street 1:601 W SPRUCE ST STE K
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4047
Practice Address - Country:US
Practice Address - Phone:406-327-3330
Practice Address - Fax:406-327-2399
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-PSY-LIC-226103T00000X, 103G00000X
MT59040103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0492524Medicaid
MT000052321OtherBCBS PROVIDER NUMBER