Healthcare Provider Details

I. General information

NPI: 1760137996
Provider Name (Legal Business Name): STEPHANIE HARRIS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MEDICAL CENTER DR
CARLETON MI
48117-9461
US

IV. Provider business mailing address

36500 FORD RD # 319
WESTLAND MI
48185-3769
US

V. Phone/Fax

Practice location:
  • Phone: 734-654-2169
  • Fax:
Mailing address:
  • Phone: 734-674-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704304359
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: