Provider Demographics
NPI:1679637391
Name:HARRIS, INDIRA MARIA WALLACE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:INDIRA
Middle Name:MARIA WALLACE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 SW GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2202
Mailing Address - Country:US
Mailing Address - Phone:954-347-6095
Mailing Address - Fax:
Practice Address - Street 1:727 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-9125
Practice Address - Country:US
Practice Address - Phone:772-595-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 75361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical