Provider Demographics
NPI:1912144213
Name:KING-HARRIS, CYNTHIA RENE'A (MS,LMHC)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:RENE'A
Last Name:KING-HARRIS
Suffix:
Gender:F
Credentials:MS,LMHC
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 6122
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6122
Mailing Address - Country:US
Mailing Address - Phone:574-298-8931
Mailing Address - Fax:
Practice Address - Street 1:3603 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3035
Practice Address - Country:US
Practice Address - Phone:574-298-8931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001737A101YM0800X
IN33001862A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker