Provider Demographics
NPI:1295107704
Name:HARRIS, SUSANNA LEE
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:LEE
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 1:220 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1737
Mailing Address - Country:US
Mailing Address - Phone:906-364-7506
Mailing Address - Fax:906-364-7508
Practice Address - Street 1:220 ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938
Practice Address - Country:US
Practice Address - Phone:906-364-7506
Practice Address - Fax:906-364-7508
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16301-132101YA0400X
MIC-03447101YA0400X
WI122960-1211041C0700X
MI68010988331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)