Provider Demographics
NPI:1508351081
Name:HARRIS, NICOLE (MA, NCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SAINT ANNS AVE APT 9C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-7881
Mailing Address - Country:US
Mailing Address - Phone:732-978-0031
Mailing Address - Fax:
Practice Address - Street 1:800 SAINT ANNS AVE APT 9C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-7881
Practice Address - Country:US
Practice Address - Phone:732-978-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101YM0800X
NY010873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNONEMedicaid