Provider Demographics
NPI:1487879631
Name:HARRIS, SUSAN NAGLE (LPPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:NAGLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 LLANO ST # B115
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5415
Mailing Address - Country:US
Mailing Address - Phone:505-603-0393
Mailing Address - Fax:505-474-6980
Practice Address - Street 1:4602 RAIL RUNNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-0807
Practice Address - Country:US
Practice Address - Phone:505-603-0393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0080601101YP2500X
NM0080601101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29885566Medicaid