Provider Demographics
NPI:1306507561
Name:HARRIS, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
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 1:515 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-5319
Mailing Address - Country:US
Mailing Address - Phone:321-361-0190
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4659
Practice Address - Country:US
Practice Address - Phone:844-854-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-09
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-201931OtherRBT
FL113402200Medicaid