Provider Demographics
NPI:1285114546
Name:HARRIS, ADINA LOUISE
Entity type:Individual
Prefix:
First Name:ADINA
Middle Name:LOUISE
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 1:7450 NW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6303
Mailing Address - Country:US
Mailing Address - Phone:954-742-3707
Mailing Address - Fax:
Practice Address - Street 1:7450 NW 51ST ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-6303
Practice Address - Country:US
Practice Address - Phone:954-742-3707
Practice Address - Fax:954-741-8773
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-2907GH320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46-4323410Medicaid