Provider Demographics
NPI:1407382773
Name:HARRISON, MONIQUE (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 CANOGA AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-7793
Practice Address - Country:US
Practice Address - Phone:909-387-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN638392084P0800X
HIMD-224972084P0800X
CAA1571682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry