Healthcare Provider Details

I. General information

NPI: 1720798903
Provider Name (Legal Business Name): TOMMY LEE HARRIS IV M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 S HARVARD AVE
TULSA OK
74114-3300
US

IV. Provider business mailing address

2750 S 8TH ST
BEAUMONT TX
77701-7719
US

V. Phone/Fax

Practice location:
  • Phone: 918-712-4301
  • Fax:
Mailing address:
  • Phone: 409-839-1000
  • Fax: 409-839-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84907
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11369
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: