Provider Demographics
NPI:1568831295
Name:HARRIS, DEMETRICE LASHAY (LMT)
Entity Type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:LASHAY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 RIVERSIDE DRIVE LN
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2669
Mailing Address - Country:US
Mailing Address - Phone:478-345-5531
Mailing Address - Fax:478-345-5531
Practice Address - Street 1:750 RIVERSIDE DRIVE LN STE 160
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2669
Practice Address - Country:US
Practice Address - Phone:478-345-5531
Practice Address - Fax:478-345-5531
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist