Provider Demographics
NPI:1487979787
Name:HARRIS, BRENDA
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-0102
Mailing Address - Country:US
Mailing Address - Phone:860-758-7267
Mailing Address - Fax:860-758-7267
Practice Address - Street 1:6 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9649
Practice Address - Country:US
Practice Address - Phone:860-758-7267
Practice Address - Fax:860-758-7267
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHCA 0000429372500000X, 374U00000X, 376J00000X, 376K00000X
CTHCA0000429372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide