Provider Demographics
NPI:1194203976
Name:HARRIS, LAWRENCE EDWARD (MA, BSW, CADC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MA, BSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 W COOK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-2533
Mailing Address - Country:US
Mailing Address - Phone:217-220-0082
Mailing Address - Fax:
Practice Address - Street 1:5230 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5128
Practice Address - Country:US
Practice Address - Phone:217-585-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL27172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)