Provider Demographics
NPI:1245712900
Name:HARRIS, STACI
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
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 1:2308 W MONTGOMERY AVE APT B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3021
Mailing Address - Country:US
Mailing Address - Phone:215-519-9183
Mailing Address - Fax:
Practice Address - Street 1:2308 W MONTGOMERY AVE APT B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3021
Practice Address - Country:US
Practice Address - Phone:215-519-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency