Provider Demographics
NPI:1366918823
Name:HARLAN, CODY RYAN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:RYAN
Last Name:HARLAN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 COPPER HILL RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3419
Mailing Address - Country:US
Mailing Address - Phone:260-578-0144
Mailing Address - Fax:
Practice Address - Street 1:1100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3462
Practice Address - Country:US
Practice Address - Phone:260-578-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002859A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer