Healthcare Provider Details

I. General information

NPI: 1649106360
Provider Name (Legal Business Name): LYNISE TAVON HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 S HAVANA ST STE 504
AURORA CO
80012-5079
US

IV. Provider business mailing address

1354 S FULTON WAY APT F206
AURORA CO
80247-6388
US

V. Phone/Fax

Practice location:
  • Phone: 857-222-0424
  • Fax:
Mailing address:
  • Phone: 720-603-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: