Provider Demographics
NPI:1003010547
Name:HARRIS, MARVA ALBERTHA
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:ALBERTHA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARVA
Other - Middle Name:ALBERTHA
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4974 EL CAJON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4677
Mailing Address - Country:US
Mailing Address - Phone:619-286-4600
Mailing Address - Fax:619-286-0060
Practice Address - Street 1:4335 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-6613
Practice Address - Country:US
Practice Address - Phone:619-358-5665
Practice Address - Fax:619-358-5665
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHDC70114FMedicaid