Healthcare Provider Details

I. General information

NPI: 1366859795
Provider Name (Legal Business Name): HERBERT HARRIS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17563 KENTUCKY ST
DETROIT MI
48221-2408
US

IV. Provider business mailing address

17563 KENTUCKY ST
DETROIT MI
48221-2408
US

V. Phone/Fax

Practice location:
  • Phone: 313-927-2779
  • Fax: 313-826-0565
Mailing address:
  • Phone: 313-733-4859
  • Fax: 313-826-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6802064962
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: