Provider Demographics
NPI:1053685313
Name:HARRIS, GLORIA (LISAC)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7518 S 12TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5831
Mailing Address - Country:US
Mailing Address - Phone:520-280-8009
Mailing Address - Fax:480-393-7598
Practice Address - Street 1:9005 N 29TH AVE UNIT 1&2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-3465
Practice Address - Country:US
Practice Address - Phone:602-354-8515
Practice Address - Fax:602-354-7751
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)