Provider Demographics
NPI:1962008060
Name:HARRIS, TAYLOR MALCOLM
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MALCOLM
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1518
Mailing Address - Country:US
Mailing Address - Phone:920-470-2394
Mailing Address - Fax:
Practice Address - Street 1:330 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1518
Practice Address - Country:US
Practice Address - Phone:920-470-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator