Provider Demographics
NPI:1780947218
Name:HARRIS, KRISTIN NICOLE (MS ED, BCBA)
Entity type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 THOMPSON HAY PATH
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1330
Mailing Address - Country:US
Mailing Address - Phone:631-682-0153
Mailing Address - Fax:
Practice Address - Street 1:73 THOMPSON HAY PATH
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1330
Practice Address - Country:US
Practice Address - Phone:631-682-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY000369-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2167178OtherPUBLIC SCHOOL TEACHER CERTIFICATE