Provider Demographics
NPI:1043350895
Name:HARRIS, RENEE (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29279 WILLOWICK CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1713
Mailing Address - Country:US
Mailing Address - Phone:248-885-0471
Mailing Address - Fax:248-977-5462
Practice Address - Street 1:43902 WOODWARD AVE STE 230
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5022
Practice Address - Country:US
Practice Address - Phone:248-481-8428
Practice Address - Fax:248-977-5462
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010716742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212673Medicaid
MI2605801692OtherBC
MI4212673Medicaid
H18000Medicare UPIN