Provider Demographics
NPI:1972278117
Name:HARRIS, THERESA ANNE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 SAINT PAUL DR
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1315
Mailing Address - Country:US
Mailing Address - Phone:573-748-0806
Mailing Address - Fax:
Practice Address - Street 1:760 PLANTATION BLVD
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5736
Practice Address - Country:US
Practice Address - Phone:573-748-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140085361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical