Basic Information
| Provider Information | |||||||||
| NPI: | 1174098115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARBISON | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | RAYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 W RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636509123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5739156531 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 WARRIOR LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639018685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736861200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2018 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.