Provider Demographics
NPI:1366833832
Name:HARRIS, ANTIONETTE MICHELLE (PPC)
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:MICHELLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 BIG LOST DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-3605
Mailing Address - Country:US
Mailing Address - Phone:402-980-3461
Mailing Address - Fax:
Practice Address - Street 1:1001 S DOUGLAS HWY STE 110
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4951
Practice Address - Country:US
Practice Address - Phone:307-686-9422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-872101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional