Healthcare Provider Details

I. General information

NPI: 1043031230
Provider Name (Legal Business Name): SHAWNTAI L HARRIS QMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 ROBERTS LN NE
WARREN OH
44483-3623
US

IV. Provider business mailing address

104 JAVIT CT
AUSTINTOWN OH
44515-2439
US

V. Phone/Fax

Practice location:
  • Phone: 716-908-1641
  • Fax:
Mailing address:
  • Phone: 330-797-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: