Healthcare Provider Details

I. General information

NPI: 1750297941
Provider Name (Legal Business Name): MRS. MARIETTA L HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SPRINGFIELD ST
DAYTON OH
45431-1084
US

IV. Provider business mailing address

4801 SPRINGFIELD ST
DAYTON OH
45431-1084
US

V. Phone/Fax

Practice location:
  • Phone: 937-236-9965
  • Fax: 937-496-7426
Mailing address:
  • Phone: 937-236-9965
  • Fax: 937-496-7426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number01499
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: