Provider Demographics
NPI:1245763176
Name:HARRIS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:111 THORNFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9150
Mailing Address - Country:US
Mailing Address - Phone:803-738-5938
Mailing Address - Fax:
Practice Address - Street 1:111 THORNFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9150
Practice Address - Country:US
Practice Address - Phone:803-738-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576000922Medicaid