Provider Demographics
NPI:1043362494
Name:HARRIS, GLORIA BRINSON (PHD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:BRINSON
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:ANN
Other - Last Name:BRINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:7 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854
Mailing Address - Country:US
Mailing Address - Phone:334-756-9411
Mailing Address - Fax:334-756-9448
Practice Address - Street 1:7 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854
Practice Address - Country:US
Practice Address - Phone:334-756-9411
Practice Address - Fax:334-756-9448
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1164103G00000X, 103TC0700X
GA2355103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA206934OtherBCBS
GA68BBFQJMedicare ID - Type Unspecified
GA206934OtherBCBS