Provider Demographics
NPI:1356807200
Name:HARRIS, RODERICK LAVELLE JR
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:LAVELLE
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 SHED RD APT 234E
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3036
Mailing Address - Country:US
Mailing Address - Phone:318-572-2970
Mailing Address - Fax:
Practice Address - Street 1:2704 SHED RD APT 234E
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3036
Practice Address - Country:US
Practice Address - Phone:318-572-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health