Provider Demographics
NPI:1760016661
Name:HARRIS, TAVARES LARON (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TAVARES
Middle Name:LARON
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 THE OAKS
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 METROPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-3111
Practice Address - Country:US
Practice Address - Phone:254-778-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN247042363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health