Provider Demographics
NPI:1841373529
Name:HARRIS, GARY D (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 MACCORKLE AVE SW
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-766-6555
Mailing Address - Fax:304-768-2335
Practice Address - Street 1:4501 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 402
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-766-6555
Practice Address - Fax:304-768-2335
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0053231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9460024Medicaid
WV9460024Medicaid
WVHA0685452Medicare ID - Type UnspecifiedANOTHER MEDICARE NUMBER