Basic Information
| Provider Information | |||||||||
| NPI: | 1225091903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | PATRICE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 908 | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745020908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184260240 | ||||||||
| FaxNumber: | 9184234051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 E VAN BUREN AVE | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184260240 | ||||||||
| FaxNumber: | 9184234051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 59 | OK | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 74502A045 | 01 | OK | CHAMPUS (WPS) | OTHER | 0166707 | 01 | OK | UMWA | OTHER | 731310891028 | 01 | OK | TRICARE SOUTH | OTHER | 731310891006 | 01 | OK | UNICARE | OTHER | D35047 | 01 | OK | STERLING OPTION 1 | OTHER |