Provider Demographics
NPI:1942993423
Name:HARRIS, NEQUANJA
Entity Type:Individual
Prefix:
First Name:NEQUANJA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NEQUANJA
Other - Middle Name:
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10450 PENNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6728
Mailing Address - Country:US
Mailing Address - Phone:517-282-4681
Mailing Address - Fax:
Practice Address - Street 1:3054 S 9TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6250
Practice Address - Country:US
Practice Address - Phone:269-332-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023023101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional