Healthcare Provider Details

I. General information

NPI: 1457552952
Provider Name (Legal Business Name): PETER RUSTIN HARRIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 17TH AVE S
NASHVILLE TN
37212-2804
US

IV. Provider business mailing address

1410 17TH AVE S
NASHVILLE TN
37212-2804
US

V. Phone/Fax

Practice location:
  • Phone: 615-279-3663
  • Fax: 615-297-8228
Mailing address:
  • Phone: 615-279-3663
  • Fax: 615-297-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2480
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: