Provider Demographics
NPI:1235641705
Name:HARRIS, REBA LEE (CO60389581)
Entity Type:Individual
Prefix:
First Name:REBA
Middle Name:LEE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CO60389581
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31912 LITTLE BOSTON RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9700
Mailing Address - Country:US
Mailing Address - Phone:360-297-6326
Mailing Address - Fax:
Practice Address - Street 1:7550 LITTLE BOSTON ROAD N.E
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346
Practice Address - Country:US
Practice Address - Phone:360-297-6326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60389581101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)