Provider Demographics
NPI:1164308193
Name:HARRIS, MICHELLE LYNN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
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 1:705 S PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2629
Mailing Address - Country:US
Mailing Address - Phone:304-446-2336
Mailing Address - Fax:304-446-2336
Practice Address - Street 1:705 S PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2629
Practice Address - Country:US
Practice Address - Phone:304-446-2336
Practice Address - Fax:304-410-0915
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25-996SUD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist