Provider Demographics
NPI:1194979633
Name:HARRIS, NICOLE RENEE (LLMSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RENEE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 915
Mailing Address - Street 2:555 TOWNER
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-544-3050
Mailing Address - Fax:734-544-6726
Practice Address - Street 1:555 TOWNER
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-544-3050
Practice Address - Fax:734-544-6726
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010860841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical