Provider Demographics
NPI:1639830847
Name:HARRIS, MISTY JEAN
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:JEAN
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 1:500 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602
Mailing Address - Country:US
Mailing Address - Phone:540-313-4196
Mailing Address - Fax:540-686-7906
Practice Address - Street 1:500 PEGASUS CT
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4596
Practice Address - Country:US
Practice Address - Phone:540-504-7257
Practice Address - Fax:540-686-7906
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0711000473101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)