MEDICARE: MS. VITA KAY HARRIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	178.013064	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1891119590	OTHER	IL	RIMYA

General Provider Information

NPI Number	:	1336630623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VITA KAY HARRIS

Provider Business Mailing Address
First Line	:	8110 S PRINCETON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-1716
Country	:	US
Telephone Number	:	312-933-9697
Fax Number	:

Provider Business Practice Location Address
First Line	:	5642 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1353
Country	:	US
Telephone Number	:	708-465-1293
Fax Number	:	708-575-3167

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2018
Last Update Date	:	05/23/2018

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