Provider Demographics
NPI:1407262678
Name:HARRIS, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 W GOOD HOPE RD APT 7
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2362
Mailing Address - Country:US
Mailing Address - Phone:414-263-9989
Mailing Address - Fax:
Practice Address - Street 1:3707 W GOOD HOPE RD APT 7
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2362
Practice Address - Country:US
Practice Address - Phone:414-554-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
WI251S00000X, 320800000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407262678Medicaid