Provider Demographics
NPI:1336630623
Name:HARRIS, VITA KAY
Entity Type:Individual
Prefix:MS
First Name:VITA
Middle Name:KAY
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 1:8110 S PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-1716
Mailing Address - Country:US
Mailing Address - Phone:312-933-9697
Mailing Address - Fax:
Practice Address - Street 1:5642 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1353
Practice Address - Country:US
Practice Address - Phone:708-465-1293
Practice Address - Fax:708-575-3167
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013064101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1891119590OtherRIMYA