Provider Demographics
NPI:1386682102
Name:HARRIS, ROSETTA WALKER (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSETTA
Middle Name:WALKER
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FREEDOM ST
Mailing Address - Street 2:PO BOX 159
Mailing Address - City:ITTA BENA
Mailing Address - State:MS
Mailing Address - Zip Code:38941-2507
Mailing Address - Country:US
Mailing Address - Phone:662-392-2871
Mailing Address - Fax:
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:840 TRUST MARK BLDG.
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC1817101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health