Provider Demographics
NPI:1669498713
Name:HARRIS, LARRY MARK (LMSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MARK
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:L
Other - Middle Name:MARK
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2820 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829
Mailing Address - Country:US
Mailing Address - Phone:906-233-1236
Mailing Address - Fax:906-233-1235
Practice Address - Street 1:200 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-233-1236
Practice Address - Fax:906-233-1235
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010849161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical