Basic Information
| Provider Information | |||||||||
| NPI: | 1700498912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1716 FORDEM AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082213511 | ||||||||
| FaxNumber: | 6088075675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1716 FORDEM AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082213511 | ||||||||
| FaxNumber: | 6088075675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2429 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2429 | 01 | WI | WISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES | OTHER |