Provider Demographics
NPI:1487603544
Name:HARRIS, ELAINE MARIE (MFT)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-0025
Mailing Address - Country:US
Mailing Address - Phone:714-437-7400
Mailing Address - Fax:714-437-7410
Practice Address - Street 1:802 MAGNOLIA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3104
Practice Address - Country:US
Practice Address - Phone:714-437-7400
Practice Address - Fax:714-737-7410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT18861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT18861OtherSTATE LICENSE