Provider Demographics
NPI:1912640525
Name:HARRIS, KATINA MARIE (AAS/QMHS3)
Entity Type:Individual
Prefix:MRS
First Name:KATINA
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:AAS/QMHS3
Other - Prefix:MISS
Other - First Name:KATINA
Other - Middle Name:MARIE
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1983
Mailing Address - Country:US
Mailing Address - Phone:937-293-8300
Mailing Address - Fax:877-287-8165
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0486113Medicaid