Provider Demographics
NPI:1285757583
Name:HARRIS, BEN (MSW)
Entity type:Individual
Prefix:MR
First Name:BEN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:LAYNE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:4479 W 4000 N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3192
Mailing Address - Country:US
Mailing Address - Phone:208-716-3280
Mailing Address - Fax:
Practice Address - Street 1:2235 E 25TH ST STE 190
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7539
Practice Address - Country:US
Practice Address - Phone:208-991-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health