Provider Demographics
NPI:1215453121
Name:HARRIS, MICHELLE FULLER (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:FULLER
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEIGH
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:DUPLESSIS
Mailing Address - State:LA
Mailing Address - Zip Code:70728-0096
Mailing Address - Country:US
Mailing Address - Phone:225-931-2653
Mailing Address - Fax:225-677-8666
Practice Address - Street 1:39094 N ANGELLE CT
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-931-2653
Practice Address - Fax:225-677-8666
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAN5503731041S0200X
LA37571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2486632Medicaid