Provider Demographics
NPI:1356833495
Name:HARRIS, TROY (BS, SAC-IT)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:BS, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2534
Mailing Address - Country:US
Mailing Address - Phone:608-633-8065
Mailing Address - Fax:
Practice Address - Street 1:618 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2534
Practice Address - Country:US
Practice Address - Phone:608-633-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18480-130101YA0400X
WI16428-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003150004Medicaid