Provider Demographics
NPI:1356534739
Name:HARRIS, LAURA LOVE (MS, CCC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LOVE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-0242
Mailing Address - Country:US
Mailing Address - Phone:601-857-0556
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N
Practice Address - Street 2:SUITE 291, HIGHLAND VILLAGE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5930
Practice Address - Country:US
Practice Address - Phone:601-362-0859
Practice Address - Fax:601-362-0870
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120957Medicaid