Provider Demographics
NPI:1992567531
Name:HARRRIS, SAMUEL OLIVER
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OLIVER
Last Name:HARRRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5408 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62207-2429
Mailing Address - Country:US
Mailing Address - Phone:314-616-9498
Mailing Address - Fax:
Practice Address - Street 1:8 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1345
Practice Address - Country:US
Practice Address - Phone:314-616-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health