Provider Demographics
NPI:1558895722
Name:HARRY, TRISTON
Entity Type:Individual
Prefix:
First Name:TRISTON
Middle Name:
Last Name:HARRY
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 1:2707 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61254
Mailing Address - Country:US
Mailing Address - Phone:309-779-2031
Mailing Address - Fax:
Practice Address - Street 1:5500 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1132
Practice Address - Country:US
Practice Address - Phone:303-730-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
COCSW.099281381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker