Provider Demographics
NPI:1689277907
Name:HARRIS, MONAE T (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MONAE
Middle Name:T
Last Name:HARRIS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 MILLER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3604
Mailing Address - Country:US
Mailing Address - Phone:414-672-3801
Mailing Address - Fax:
Practice Address - Street 1:1610 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:262-214-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19319101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)