Provider Demographics
NPI:1316301328
Name:HARRIS, SHIRLEY ANN
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12750 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1624
Mailing Address - Country:US
Mailing Address - Phone:313-397-8179
Mailing Address - Fax:313-397-8519
Practice Address - Street 1:12750 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1624
Practice Address - Country:US
Practice Address - Phone:313-397-8179
Practice Address - Fax:313-397-8519
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010978081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical