Provider Demographics
NPI:1215434659
Name:HARRIS, ALISSA RAE (LBA, LMHC)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:RAE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LBA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 MOLE PL
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9349
Mailing Address - Country:US
Mailing Address - Phone:808-868-9536
Mailing Address - Fax:
Practice Address - Street 1:161 S WAKEA AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1343
Practice Address - Country:US
Practice Address - Phone:808-244-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC-845101YP2500X
HI227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1922870302Medicaid