Provider Demographics
NPI:1255371142
Name:HARRISON, JAMES LOUIS III (MS, CSAC, LPC, NCGC-)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LOUIS
Last Name:HARRISON
Suffix:III
Gender:M
Credentials:MS, CSAC, LPC, NCGC-
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Mailing Address - Street 1:10012 WEST CAPITOL DRIVE, SUITE 101
Mailing Address - Street 2:WEST GROVE CLINIC, LLC
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222
Mailing Address - Country:US
Mailing Address - Phone:414-810-4844
Mailing Address - Fax:414-810-4845
Practice Address - Street 1:10012 WEST CAPITOL DRIVE, SUITE 101
Practice Address - Street 2:WEST GROVE CLINIC, LLC
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222
Practice Address - Country:US
Practice Address - Phone:414-810-4844
Practice Address - Fax:414-810-4845
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI13018101YA0400X
WI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100024752Medicaid
WI42019700Medicaid