Provider Demographics
NPI:1053547430
Name:HARRELSON, WILLIAM FRED (LMT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FRED
Last Name:HARRELSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 SW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-3701
Mailing Address - Country:US
Mailing Address - Phone:954-627-2773
Mailing Address - Fax:
Practice Address - Street 1:3113 SW 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-3701
Practice Address - Country:US
Practice Address - Phone:954-627-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0BMA53595225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist