Provider Demographics
NPI:1245376516
Name:HARRIS, DALE G
Entity type:Individual
Prefix:MRS
First Name:DALE
Middle Name:G
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 1:2704 NW 46TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-1213
Mailing Address - Country:US
Mailing Address - Phone:352-336-0208
Mailing Address - Fax:
Practice Address - Street 1:2704 NW 46TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-1213
Practice Address - Country:US
Practice Address - Phone:352-336-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7675836Medicaid