Provider Demographics
NPI:1407909575
Name:HARRIS, MARY J (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 AGATE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7802
Mailing Address - Country:US
Mailing Address - Phone:505-623-3466
Mailing Address - Fax:
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-637-3425
Practice Address - Fax:505-627-2544
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93304064Medicaid