Provider Demographics
NPI:1437208931
Name:HARRIS, MICHAEL J (MSW, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S WOODRUFF AVE
Mailing Address - Street 2:A4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4369
Mailing Address - Country:US
Mailing Address - Phone:208-529-5548
Mailing Address - Fax:208-529-5588
Practice Address - Street 1:211 S WOODRUFF AVE
Practice Address - Street 2:A4
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4369
Practice Address - Country:US
Practice Address - Phone:208-529-5548
Practice Address - Fax:208-529-5588
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-4201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1690233Medicare ID - Type Unspecified