Provider Demographics
NPI:1447564612
Name:HARRIS, PEONITA (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:PEONITA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5918
Mailing Address - Country:US
Mailing Address - Phone:847-828-8196
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE
Practice Address - Street 2:LL21
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5918
Practice Address - Country:US
Practice Address - Phone:847-828-8196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist