Basic Information
| Provider Information | |||||||||
| NPI: | 1003010547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MARVA | ||||||||
| MiddleName: | ALBERTHA | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEWIS | ||||||||
| OtherFirstName: | MARVA | ||||||||
| OtherMiddleName: | ALBERTHA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4974 EL CAJON BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921154677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192864600 | ||||||||
| FaxNumber: | 6192860060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4335 SWIFT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921046613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193585665 | ||||||||
| FaxNumber: | 6193585665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | HDC70114F | 05 | CA | MEDICAID |