Provider Demographics
NPI:1306134572
Name:HARRIS, NICHOLE LANETTE (PC)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:LANETTE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4488 W BROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-5610
Mailing Address - Country:US
Mailing Address - Phone:614-870-6770
Mailing Address - Fax:614-870-6855
Practice Address - Street 1:655 SHERIDAN AVENUE
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209
Practice Address - Country:US
Practice Address - Phone:614-551-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0602081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional