Provider Demographics
NPI:1487751996
Name:HARRIS, LAURA LEE (LMT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:LEE
Other - Last Name:WHITESIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2625 MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-545-9654
Mailing Address - Fax:904-388-0977
Practice Address - Street 1:5135 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-388-0900
Practice Address - Fax:904-388-0977
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41894225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist