Basic Information
Provider Information | |||||||||
NPI: | 1568120699 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | CA | ||||||||
PostalCode: | 959719375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075996473 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 702-130 RICHMOND RD E | ||||||||
Address2: |   | ||||||||
City: | SUSANVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 961305029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302575644 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2021 | ||||||||
LastUpdateDate: | 03/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 101843 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225C00000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |   |
No ID Information.