Provider Demographics
NPI:1992003412
Name:HARRISON, MARVEL E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARVEL
Middle Name:E
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 SAN ILDEFONSO RD
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2735
Mailing Address - Country:US
Mailing Address - Phone:505-412-3367
Mailing Address - Fax:505-662-9200
Practice Address - Street 1:3917 WEST ROAD
Practice Address - Street 2:SUITE M250
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-412-3367
Practice Address - Fax:505-662-9200
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health