Healthcare Provider Details

I. General information

NPI: 1992003412
Provider Name (Legal Business Name): MARVEL E. HARRISON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST ROAD SUITE M250
LOS ALAMOS NM
87544
US

IV. Provider business mailing address

199 SAN ILDEFONSO RD
LOS ALAMOS NM
87544-2735
US

V. Phone/Fax

Practice location:
  • Phone: 505-412-3367
  • Fax: 505-662-9200
Mailing address:
  • Phone: 505-412-3367
  • Fax: 505-662-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1534
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: