Provider Demographics
NPI:1477677151
Name:HARRIS, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
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 1:20505 DUPONT BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-3173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20505 DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-3173
Practice Address - Country:US
Practice Address - Phone:302-856-1835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE144101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000035744Medicaid