Provider Demographics
NPI:1164581724
Name:HARRIS, MYRA GWEN (MFT)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:GWEN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KAISER PERMANENTE 800 SERENO DR.
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589
Mailing Address - Country:US
Mailing Address - Phone:707-651-2623
Mailing Address - Fax:707-651-2608
Practice Address - Street 1:KAISER PERMANENTE 800 SERENO DR.
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-651-2623
Practice Address - Fax:707-651-2608
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32829106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist