Provider Demographics
NPI:1902142003
Name:HARRIS, THEODORE R (LCSW, CADC)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 ASBURY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1637
Mailing Address - Country:US
Mailing Address - Phone:773-680-1534
Mailing Address - Fax:312-674-7515
Practice Address - Street 1:820 DAVIS ST STE 453
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4447
Practice Address - Country:US
Practice Address - Phone:312-576-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0161131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical