Healthcare Provider Details

I. General information

NPI: 1801314331
Provider Name (Legal Business Name): THOMAS BENJAMIN HARRIS PLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 KEATON CROSSING BLVD STE 204
O FALLON MO
63368-8223
US

IV. Provider business mailing address

4132 KEATON CROSSING BLVD STE 204
O FALLON MO
63368-8223
US

V. Phone/Fax

Practice location:
  • Phone: 636-627-9136
  • Fax:
Mailing address:
  • Phone: 636-627-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2016014344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: