Provider Demographics
NPI:1073524005
Name:HARRIS, CHARLES SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 MAGNOLIA DALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545
Mailing Address - Country:US
Mailing Address - Phone:832-474-0812
Mailing Address - Fax:281-888-3675
Practice Address - Street 1:1230 MAGNOLIA DALE DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-9680
Practice Address - Country:US
Practice Address - Phone:832-474-0812
Practice Address - Fax:281-888-3675
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156608504Medicaid
TX156608503Medicaid
TX8J2846Medicare PIN