Provider Demographics
NPI:1104258623
Name:HARRIS, SUSAN BETH
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BETH
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-6133
Mailing Address - Country:US
Mailing Address - Phone:844-458-2100
Mailing Address - Fax:
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst