MEDICARE: HIAWATHA HARRIS MD INC.

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	103TF0000X	Family Psychologist	C22371	CA
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist	C22371	CA
3	106H00000X	Marriage & Family Therapist	C22371	CA
4	101YM0800X	Mental Health Counselor	C22371	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942420724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIAWATHA HARRIS MD INC.

Provider Business Mailing Address
First Line	:	5674 STONERIDGE DR
Second Line	:	SUITE 207
City	:	PLEASANTON
State	:	CA
Zip	:	94588-8500
Country	:	US
Telephone Number	:	925-520-0005
Fax Number	:	925-520-0010

Provider Business Practice Location Address
First Line	:	1970 BROADWAY STE 250
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94612-2214
Country	:	US
Telephone Number	:	510-273-4200
Fax Number	:	510-273-8340

Authorized Official
Title or Position	:	CEO
Name	:	NEISHA BECTON
Credential	:
Telephone Number	:	925-520-0005

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	08/16/2024

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