Provider Demographics
NPI:1417340688
Name:HARRIS, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:4064 RACE TRACK RD
Mailing Address - Street 2:
Mailing Address - City:GRIFTON
Mailing Address - State:NC
Mailing Address - Zip Code:28530-7304
Mailing Address - Country:US
Mailing Address - Phone:252-523-4687
Mailing Address - Fax:
Practice Address - Street 1:4064 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:GRIFTON
Practice Address - State:NC
Practice Address - Zip Code:28530-7304
Practice Address - Country:US
Practice Address - Phone:252-523-4687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0093841041C0700X
NC21642A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)