Provider Demographics
NPI:1386978393
Name:HARRIS, MARCIA L
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:L
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 1:1 JEFFERSON BARRACKS DRIVE
Mailing Address - Street 2:SAINT LOUIS VETERANS AFFAIRS MEDICAL CENTER
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125
Mailing Address - Country:US
Mailing Address - Phone:314-862-4100
Mailing Address - Fax:314-289-6581
Practice Address - Street 1:1 JEFFERSON BARRACKS DRIVE
Practice Address - Street 2:SAINT LOUIS VETERANS AFFAIRS MEDICAL CENTER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125
Practice Address - Country:US
Practice Address - Phone:314-862-4100
Practice Address - Fax:314-289-6581
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5229174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5229OtherVISION REHABILITATION THERAPY CERTIFICATE