Provider Demographics
NPI:1699247866
Name:HARRIS, KATRINA LORENE (LMSW-CLINICAL)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LORENE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 MARYGROVE DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2942
Mailing Address - Country:US
Mailing Address - Phone:313-914-9471
Mailing Address - Fax:
Practice Address - Street 1:8441 MARYGROVE DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2942
Practice Address - Country:US
Practice Address - Phone:313-914-9471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011153751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871893065Medicaid
MI1417305582Medicaid