Basic Information
| Provider Information | |||||||||
| NPI: | 1356523716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | NEMOURS CHILDRENS CLINIC | ||||||||
| Address2: | P.O. BOX 404112 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043903610 | ||||||||
| FaxNumber: | 9042885890 | ||||||||
| Practice Location | |||||||||
| Address1: | A.I. DUPONT HOSPITAL FOR CHILDREN | ||||||||
| Address2: | 1600 ROCKLAND ROAD | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | 103TC0700X | B10000777 | DE | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP2701X | B10000777 | DE | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
ID Information
| ID | Type | State | Issuer | Description | 4138473 | 05 | MD | MEDICAID | 102087416 | 05 | PA | MEDICAID | 147192 | 05 | NJ | MEDICAID |