Provider Demographics
NPI:1639220627
Name:HARRIS, GENE DAVID (PHD)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:DAVID
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2001 ABBOT RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1400
Mailing Address - Country:US
Mailing Address - Phone:517-337-6545
Mailing Address - Fax:517-337-3010
Practice Address - Street 1:2001 ABBOT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1400
Practice Address - Country:US
Practice Address - Phone:517-337-6545
Practice Address - Fax:517-337-3010
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS97373Medicare UPIN
MIC36456008Medicare ID - Type Unspecified