Provider Demographics
NPI:1326787391
Name:HARRIS, MARDAYSHA
Entity Type:Individual
Prefix:
First Name:MARDAYSHA
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 1:3663 HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5568
Mailing Address - Country:US
Mailing Address - Phone:352-777-0293
Mailing Address - Fax:
Practice Address - Street 1:3663 HARVEST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5568
Practice Address - Country:US
Practice Address - Phone:352-777-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-29
Last Update Date:2022-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103TS0200X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool