Provider Demographics
NPI:1811620917
Name:HARRIS, NICHELLE CYMONE
Entity type:Individual
Prefix:MRS
First Name:NICHELLE
Middle Name:CYMONE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5127 TUTTLE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-1686
Mailing Address - Country:US
Mailing Address - Phone:732-877-4901
Mailing Address - Fax:
Practice Address - Street 1:404 N BAUGHMAN ST
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2058
Practice Address - Country:US
Practice Address - Phone:620-275-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional