Provider Demographics
NPI:1710044763
Name:HARRIS, MARTHA P (PHD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:P
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 MT DIABLO BLVD
Mailing Address - Street 2:B201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549
Mailing Address - Country:US
Mailing Address - Phone:925-284-4426
Mailing Address - Fax:925-284-1599
Practice Address - Street 1:3468 MT DIABLO BLVD
Practice Address - Street 2:B201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549
Practice Address - Country:US
Practice Address - Phone:925-284-4426
Practice Address - Fax:925-284-1599
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17485103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P55362Medicare UPIN
CA0PL174850Medicare ID - Type Unspecified