Healthcare Provider Details

I. General information

NPI: 1093245961
Provider Name (Legal Business Name): FREDERICK HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 SEMINOLE CENTRE CT STE C
FITCHBURG WI
53711-5165
US

IV. Provider business mailing address

5930 SEMINOLE CENTRE CT STE C
FITCHBURG WI
53711-5165
US

V. Phone/Fax

Practice location:
  • Phone: 608-630-8889
  • Fax: 608-200-7268
Mailing address:
  • Phone: 608-630-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6374-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: