Provider Demographics
NPI:1457552952
Name:HARRIS, PETER RUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:RUSTIN
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-2804
Mailing Address - Country:US
Mailing Address - Phone:615-279-3663
Mailing Address - Fax:615-297-8228
Practice Address - Street 1:1410 17TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2804
Practice Address - Country:US
Practice Address - Phone:615-279-3663
Practice Address - Fax:615-297-8228
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2480103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4127465Medicare UPIN