Provider Demographics
NPI:1265905889
Name:HARRIS, MARY KATHERINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
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 1:6802 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6802
Mailing Address - Country:US
Mailing Address - Phone:435-797-8436
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6802 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6802
Practice Address - Country:US
Practice Address - Phone:435-797-8436
Practice Address - Fax:844-308-5865
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11090381-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst