Provider Demographics
NPI:1386037554
Name:HARRIS, BRENDA (LICDC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5234 W STATE ROUTE 63
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8202
Mailing Address - Country:US
Mailing Address - Phone:513-933-9304
Mailing Address - Fax:
Practice Address - Street 1:5234 W STATE ROUTE 63
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8202
Practice Address - Country:US
Practice Address - Phone:513-933-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)