Basic Information
Provider Information | |||||||||
NPI: | 1750713368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | FRANK | ||||||||
MiddleName: | DARRYL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, CADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 411 N KENNETH CT | ||||||||
Address2: |   | ||||||||
City: | GLENWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 604251205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082755886 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5517 N KENMORE AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606401515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732757962 | ||||||||
FaxNumber: | 7732750728 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2013 | ||||||||
LastUpdateDate: | 07/28/2015 | ||||||||
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 | 104100000X | 150.010429 | IL | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 101YA0400X | 21137 | IL | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.