Healthcare Provider Details

I. General information

NPI: 1972139574
Provider Name (Legal Business Name): WALTER ROBERT HARRIS ME
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 STONECREST CT
SHELBYVILLE KY
40065-8128
US

IV. Provider business mailing address

30 STONECREST CT
SHELBYVILLE KY
40065-8128
US

V. Phone/Fax

Practice location:
  • Phone: 502-437-0859
  • Fax: 502-324-7057
Mailing address:
  • Phone: 502-232-0893
  • Fax: 502-324-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: