Provider Demographics
NPI:1942537477
Name:HARRIS, MIKKAL (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MIKKAL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8660 S 86TH AVE
Mailing Address - Street 2:#310
Mailing Address - City:JUSTICE
Mailing Address - State:IL
Mailing Address - Zip Code:60458-2127
Mailing Address - Country:US
Mailing Address - Phone:773-733-1773
Mailing Address - Fax:708-458-7930
Practice Address - Street 1:4749 LINCOLN MALL DR
Practice Address - Street 2:#202
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2348
Practice Address - Country:US
Practice Address - Phone:708-833-8887
Practice Address - Fax:708-827-0555
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007145101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist