Provider Demographics
NPI:1467951145
Name:HARRIS, ANGELA RENEE (TCADC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 RALPH AVE APT 518
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-2219
Mailing Address - Country:US
Mailing Address - Phone:270-316-0900
Mailing Address - Fax:
Practice Address - Street 1:202 W 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4123
Practice Address - Country:US
Practice Address - Phone:270-693-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175412101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY175412OtherTCADC