Basic Information
| Provider Information | |||||||||
| NPI: | 1811221393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CADAC IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 809 | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465270809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465171533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 09/30/2009 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.