Healthcare Provider Details

I. General information

NPI: 1750713368
Provider Name (Legal Business Name): FRANK DARRYL HARRIS LCSW, CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 N KENMORE AVE
CHICAGO IL
60640-1515
US

IV. Provider business mailing address

411 N KENNETH CT
GLENWOOD IL
60425-1205
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-7962
  • Fax: 773-275-0728
Mailing address:
  • Phone: 708-275-5886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.010429
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: