Basic Information
Provider Information | |||||||||
NPI: | 1588950687 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | DALE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARRIS | ||||||||
OtherFirstName: | NICK | ||||||||
OtherMiddleName: | DALE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3645 E MCLEOD RD | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982268700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3645 E MCLEOD RD | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982268700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606762220 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2011 | ||||||||
LastUpdateDate: | 06/27/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC60222179 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.