Healthcare Provider Details

I. General information

NPI: 1518679075
Provider Name (Legal Business Name): TRAJUAN HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 COURVILLE ST
DETROIT MI
48224-2672
US

IV. Provider business mailing address

5503 COURVILLE ST
DETROIT MI
48224-2672
US

V. Phone/Fax

Practice location:
  • Phone: 313-747-0021
  • Fax:
Mailing address:
  • Phone: 313-747-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number2813308004
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: