Provider Demographics
NPI:1255228797
Name:HARRIS, ANGELA RAE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
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 1:23 MARY MAC LOOP
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-1823
Mailing Address - Country:US
Mailing Address - Phone:317-250-0721
Mailing Address - Fax:
Practice Address - Street 1:4 DAVIS RD W
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371
Practice Address - Country:US
Practice Address - Phone:860-531-9621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2168103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst