Provider Demographics
NPI:1083262505
Name:HARRIS, LISA MONIQUE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MONIQUE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-1502
Mailing Address - Country:US
Mailing Address - Phone:559-237-3420
Mailing Address - Fax:
Practice Address - Street 1:611 BELMONT
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728
Practice Address - Country:US
Practice Address - Phone:559-237-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083262505OtherMEDICAL
3512OtherSECURITY CODE