Provider Demographics
NPI:1053782003
Name:HARRIS, MYA (LCSW)
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MYA
Other - Middle Name:ANGELOU
Other - Last Name:BURICH COOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MS 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7451
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:3040 N 117TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4128
Practice Address - Country:US
Practice Address - Phone:414-479-9990
Practice Address - Fax:414-479-0230
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8343-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053782003Medicaid