Provider Demographics
NPI:1790968501
Name:HARRIS, MARVIN D (MA)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 S HARPER AVE APT C1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4194
Mailing Address - Country:US
Mailing Address - Phone:773-699-2470
Mailing Address - Fax:
Practice Address - Street 1:4655 S KING DR
Practice Address - Street 2:SUITE 105
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4138
Practice Address - Country:US
Practice Address - Phone:773-699-2470
Practice Address - Fax:773-268-8756
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006699101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional