Provider Demographics
NPI:1326440991
Name:HARRIS, DEMETRIA
Entity Type:Individual
Prefix:
First Name:DEMETRIA
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 1:455 N MESA DR STE 11
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5936
Mailing Address - Country:US
Mailing Address - Phone:480-207-7560
Mailing Address - Fax:480-668-3439
Practice Address - Street 1:455 N. MESA DRIVE #11
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-262-3848
Practice Address - Fax:480-668-3439
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6493101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC6493OtherARIZONA DEPARTMENT OF HEALTH SERVICES