Provider Demographics
NPI:1508923517
Name:HARRIS, MITCHELL EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:EDWARD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 FOOTHILL BLVD
Mailing Address - Street 2:#61
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3451
Mailing Address - Country:US
Mailing Address - Phone:909-596-3577
Mailing Address - Fax:909-593-6456
Practice Address - Street 1:12530 10TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3520
Practice Address - Country:US
Practice Address - Phone:909-596-3577
Practice Address - Fax:909-593-6456
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07821ZOtherBLUE SHIELD OF CALIFORNIA
CAOPL80000OtherBLUE SHIELD OF CALIFORNIA
CAZZZ07821ZOtherBLUE SHIELD OF CALIFORNIA