Provider Demographics
NPI:1740907039
Name:HARRIS, TINNEAL (CADC)
Entity type:Individual
Prefix:
First Name:TINNEAL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CADC
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 34
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-0034
Mailing Address - Country:US
Mailing Address - Phone:712-243-2606
Mailing Address - Fax:
Practice Address - Street 1:304 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IA
Practice Address - Zip Code:50849-1257
Practice Address - Country:US
Practice Address - Phone:641-743-2439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00893Medicaid