1013206341 NPI number — MRS. BRENDA MARRON HARRIS LBSW

Table of content: YOON SEO RDH (NPI 1851097364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013206341 NPI number — MRS. BRENDA MARRON HARRIS LBSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
BRENDA
Provider Middle Name:
MARRON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LBSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEADOWS
Provider Other First Name:
BRENDA
Provider Other Middle Name:
MARRON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LBSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013206341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10159 BEACONSFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48224-2536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-245-7000
Provider Business Mailing Address Fax Number:
313-245-7009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20303 KELLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48225-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-245-7000
Provider Business Practice Location Address Fax Number:
313-245-7009
Provider Enumeration Date:
04/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6802069759 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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