Healthcare Provider Details

I. General information

NPI: 1083217061
Provider Name (Legal Business Name): MARK HARRIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21205 SOPHIA DR
MATTESON IL
60443-1860
US

IV. Provider business mailing address

21205 SOPHIA DR
MATTESON IL
60443-1860
US

V. Phone/Fax

Practice location:
  • Phone: 708-271-7363
  • Fax:
Mailing address:
  • Phone: 708-271-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149026521
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: