Provider Demographics
NPI:1346406840
Name:HARRIS, MAXIE (PHD)
Entity Type:Individual
Prefix:
First Name:MAXIE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 SE 1ST AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2875
Mailing Address - Country:US
Mailing Address - Phone:954-885-9500
Mailing Address - Fax:954-885-9444
Practice Address - Street 1:1848 SE 1ST AVE STE 4
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-885-9500
Practice Address - Fax:954-885-9444
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7769103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK885AMedicare PIN