Provider Demographics
NPI:1073679890
Name:HARRIS, MARK B (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
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 1:12915 JONES MALTSBERGER RD
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4255
Mailing Address - Country:US
Mailing Address - Phone:210-656-3400
Mailing Address - Fax:
Practice Address - Street 1:12915 JONES MALTSBERGER RD
Practice Address - Street 2:STE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-4255
Practice Address - Country:US
Practice Address - Phone:210-656-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1028649-04Medicaid
TX00790HMedicare ID - Type Unspecified