Provider Demographics
NPI:1932302718
Name:HARRIS, WENDELL J (MS -CADC-I)
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MS -CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N 4TH ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2362
Mailing Address - Country:US
Mailing Address - Phone:414-265-5538
Mailing Address - Fax:414-265-4533
Practice Address - Street 1:2821 N 4TH ST
Practice Address - Street 2:SUITE 224
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2362
Practice Address - Country:US
Practice Address - Phone:414-265-5538
Practice Address - Fax:414-265-4533
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15370-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42247000Medicaid
WI42247021Medicaid