Provider Demographics
NPI:1629537097
Name:HARRIS, GWENETTA A (BS)
Entity Type:Individual
Prefix:MS
First Name:GWENETTA
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 ALVIN OGDEN DR
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-8883
Mailing Address - Country:US
Mailing Address - Phone:912-339-1423
Mailing Address - Fax:912-705-6423
Practice Address - Street 1:437 W PARKER ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0605
Practice Address - Country:US
Practice Address - Phone:912-705-0858
Practice Address - Fax:912-705-6423
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional