Provider Demographics
NPI:1265005557
Name:HARRIS, DOUGLAS WILLARD (RBT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:WILLARD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 OLD REX MORROW RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3994
Mailing Address - Country:US
Mailing Address - Phone:404-553-4524
Mailing Address - Fax:
Practice Address - Street 1:2701 OLD REX MORROW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3994
Practice Address - Country:US
Practice Address - Phone:404-553-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21-176239106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician