Provider Demographics
NPI:1891382776
Name:HARRIS, TRACEE
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:
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 1:11300 W 126TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9342
Mailing Address - Country:US
Mailing Address - Phone:708-650-6051
Mailing Address - Fax:
Practice Address - Street 1:11300 W 126TH AVE
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9342
Practice Address - Country:US
Practice Address - Phone:708-650-6051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator