Provider Demographics
NPI:1003815531
Name:HARRIS, MICHAEL A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3201
Mailing Address - Country:US
Mailing Address - Phone:516-897-1883
Mailing Address - Fax:516-470-5415
Practice Address - Street 1:231 W BEECH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3201
Practice Address - Country:US
Practice Address - Phone:516-897-1883
Practice Address - Fax:516-470-5415
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR049722-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN405P1Medicare ID - Type Unspecified