Provider Demographics
NPI:1568462455
Name:HARRIS, PATRICK T (PHD)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:T
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:P
Other - Middle Name:TIM
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:195 IDLEWILD DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5323
Mailing Address - Country:US
Mailing Address - Phone:270-442-1431
Mailing Address - Fax:
Practice Address - Street 1:100 FOUNTAIN AVENUE
Practice Address - Street 2:SUITE 301
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2774
Practice Address - Country:US
Practice Address - Phone:270-443-8195
Practice Address - Fax:270-444-7922
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY687103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89000152Medicaid
CP00142Medicare ID - Type Unspecified