Provider Demographics
NPI:1508367848
Name:HARRIS, KEITH J (LCSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 W DIVERSEY AVE OFC 14
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1245
Mailing Address - Country:US
Mailing Address - Phone:224-534-0331
Mailing Address - Fax:
Practice Address - Street 1:3411 W DIVERSEY AVE OFC 14
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1245
Practice Address - Country:US
Practice Address - Phone:224-534-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490185721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical