Provider Demographics
NPI:1366859795
Name:HARRIS, HERBERT SR
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17563 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2408
Mailing Address - Country:US
Mailing Address - Phone:313-733-4859
Mailing Address - Fax:313-826-0565
Practice Address - Street 1:17563 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2408
Practice Address - Country:US
Practice Address - Phone:313-927-2779
Practice Address - Fax:313-826-0565
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802064962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health