Provider Demographics
NPI:1245994490
Name:HARRIS, MARCY GWENDELL
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:GWENDELL
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:GWENDELL
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 352
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-0352
Mailing Address - Country:US
Mailing Address - Phone:941-545-6823
Mailing Address - Fax:
Practice Address - Street 1:308 16TH ST W
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-3926
Practice Address - Country:US
Practice Address - Phone:941-545-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH620547697940OtherDRIVER LICENSE