Provider Demographics
NPI:1083465447
Name:HARRIS, TISA LASHAY
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:LASHAY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:28137-0264
Mailing Address - Country:US
Mailing Address - Phone:336-675-7154
Mailing Address - Fax:
Practice Address - Street 1:2300 W MEADOWVIEW RD STE 120
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3711
Practice Address - Country:US
Practice Address - Phone:336-675-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27896101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)