Provider Demographics
NPI:1295867174
Name:HARRIS, SERVILLA V (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SERVILLA
Middle Name:V
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5345 CHRYSLER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-4135
Mailing Address - Country:US
Mailing Address - Phone:313-871-8405
Mailing Address - Fax:
Practice Address - Street 1:25619 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2063
Practice Address - Country:US
Practice Address - Phone:313-345-3853
Practice Address - Fax:313-345-4358
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010158871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS38404Medicare UPIN