Provider Demographics
NPI:1720754229
Name:HARRIS, TREVOR KYLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:KYLE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 S BEAUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSASVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53139-9528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7300 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-6525
Practice Address - Country:US
Practice Address - Phone:262-321-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4545154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist