Healthcare Provider Details

I. General information

NPI: 1104746296
Provider Name (Legal Business Name): GREGORY FREDERICK HARRIS III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GREG TRE HARRIS

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 GRAND AVE
OAKLAND CA
94610-3554
US

IV. Provider business mailing address

614 GRAND AVE
OAKLAND CA
94610-3554
US

V. Phone/Fax

Practice location:
  • Phone: 844-638-6968
  • Fax:
Mailing address:
  • Phone: 844-638-6968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: