Provider Demographics
NPI:1386896215
Name:HARRIS, MARTY MILES (LPC)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:MILES
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:BLESSING
Mailing Address - State:TX
Mailing Address - Zip Code:77419-0193
Mailing Address - Country:US
Mailing Address - Phone:979-541-3257
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4962
Practice Address - Country:US
Practice Address - Phone:979-541-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1976300Medicaid