Healthcare Provider Details

I. General information

NPI: 1508574971
Provider Name (Legal Business Name): MARVIN LINDSAY HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2357 HAMPSTEAD DR STE 9
COLUMBUS OH
43229-2852
US

IV. Provider business mailing address

2357 HAMPSTEAD DR STE 9
COLUMBUS OH
43229-2852
US

V. Phone/Fax

Practice location:
  • Phone: 614-568-8236
  • Fax: 614-725-2829
Mailing address:
  • Phone: 614-568-8236
  • Fax: 614-725-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.178568
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.002631
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: