Provider Demographics
NPI:1346461423
Name:HARRIS, CHARLES EUGENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EUGENE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 NELSON DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3032
Mailing Address - Country:US
Mailing Address - Phone:228-875-7648
Mailing Address - Fax:228-872-9493
Practice Address - Street 1:5427-A GEX RD
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525
Practice Address - Country:US
Practice Address - Phone:228-255-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS36-620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04804801Medicaid