Provider Demographics
NPI:1518679075
Name:HARRIS, TRAJUAN
Entity Type:Individual
Prefix:
First Name:TRAJUAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5503 COURVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2672
Mailing Address - Country:US
Mailing Address - Phone:313-747-0021
Mailing Address - Fax:
Practice Address - Street 1:5503 COURVILLE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2672
Practice Address - Country:US
Practice Address - Phone:313-747-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2813308004171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach