Provider Demographics
NPI:1386957041
Name:HARRIS, DEBERAH MACKENZIE
Entity type:Individual
Prefix:
First Name:DEBERAH
Middle Name:MACKENZIE
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 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6600
Mailing Address - Fax:414-454-6450
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2504
Practice Address - Country:US
Practice Address - Phone:414-454-6600
Practice Address - Fax:414-454-6450
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4377-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional