Healthcare Provider Details

I. General information

NPI: 1376716167
Provider Name (Legal Business Name): STANFORD J. HARRIS LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-4673
  • Fax:
Mailing address:
  • Phone: 513-892-4673
  • Fax: 513-873-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.141051
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: