Provider Demographics
NPI:1962012260
Name:HARRISON, MICHAELA BLAIRE (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:BLAIRE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 NW 10TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1219
Mailing Address - Country:US
Mailing Address - Phone:618-842-4617
Mailing Address - Fax:
Practice Address - Street 1:213 NW 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1219
Practice Address - Country:US
Practice Address - Phone:618-842-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180013059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180013059Medicaid