Provider Demographics
NPI:1225668270
Name:HARRIS, EDWARD TODD III
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:TODD
Last Name:HARRIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 OAKRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1165
Mailing Address - Country:US
Mailing Address - Phone:716-430-4633
Mailing Address - Fax:
Practice Address - Street 1:224 OAKRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14217-1165
Practice Address - Country:US
Practice Address - Phone:716-430-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X, 101YP1600X, 175T00000X, 176P00000X, 177F00000X
177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No175T00000XOther Service ProvidersPeer Specialist
No176P00000XOther Service ProvidersFuneral Director