Provider Demographics
NPI:1821584285
Name:HARRIS, CARRIE ANN-BRECTO
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN-BRECTO
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 1:311 UNIVERSITY AVE NE APT 101
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2078
Mailing Address - Country:US
Mailing Address - Phone:612-821-2189
Mailing Address - Fax:
Practice Address - Street 1:311 UNIVERSITY AVE NE APT 101
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2078
Practice Address - Country:US
Practice Address - Phone:612-821-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker