MEDICARE: BRENDA HARRIS LICDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	101163	OH

General Provider Information

NPI Number	:	1386037554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA HARRIS LICDC

Provider Business Mailing Address
First Line	:	5234 W STATE ROUTE 63
Second Line	:
City	:	LEBANON
State	:	OH
Zip	:	45036-8202
Country	:	US
Telephone Number	:	513-933-9304
Fax Number	:

Provider Business Practice Location Address
First Line	:	5234 W STATE ROUTE 63
Second Line	:
City	:	LEBANON
State	:	OH
Zip	:	45036-8202
Country	:	US
Telephone Number	:	513-933-9304
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2015
Last Update Date	:	03/12/2015

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