Provider Demographics
NPI:1790393601
Name:HARRIS, LAURA JEAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 INTERSTATE DR STE D
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3409
Mailing Address - Country:US
Mailing Address - Phone:931-444-1000
Mailing Address - Fax:931-728-1229
Practice Address - Street 1:482 INTERSTATE DR STE D
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3409
Practice Address - Country:US
Practice Address - Phone:931-444-1000
Practice Address - Fax:931-728-1229
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4711101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health