Basic Information
| Provider Information | |||||||||
| NPI: | 1811178072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MA, LCPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 606 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623631308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172859601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 05/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180005830 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.