Provider Demographics
NPI:1104415975
Name:HARRIS, INDIA EVON
Entity type:Individual
Prefix:
First Name:INDIA
Middle Name:EVON
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 1:329 DIANE DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2113
Mailing Address - Country:US
Mailing Address - Phone:404-717-7673
Mailing Address - Fax:470-826-4096
Practice Address - Street 1:329 DIANE DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2113
Practice Address - Country:US
Practice Address - Phone:404-287-3769
Practice Address - Fax:470-826-4096
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007312101YP2500X
GALPC012745101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional