Provider Demographics
NPI:1629484431
Name:HARRIS, LARRY BERNARD II
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:BERNARD
Last Name:HARRIS
Suffix:II
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 1:7647 BOULDER LN
Mailing Address - Street 2:APT. J13
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-3043
Mailing Address - Country:US
Mailing Address - Phone:317-500-7991
Mailing Address - Fax:
Practice Address - Street 1:7647 BOULDER LN
Practice Address - Street 2:APT. J13
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-3043
Practice Address - Country:US
Practice Address - Phone:317-500-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201057300 AOtherMEDICAID LEGACY PROVIDER ID