Provider Demographics
NPI:1740824697
Name:HARRIS, TERRYL HEATH IX
Entity type:Individual
Prefix:
First Name:TERRYL
Middle Name:HEATH
Last Name:HARRIS
Suffix:IX
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1573
Mailing Address - Country:US
Mailing Address - Phone:413-777-5088
Mailing Address - Fax:
Practice Address - Street 1:2994 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1573
Practice Address - Country:US
Practice Address - Phone:413-777-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician