Provider Demographics
NPI:1659663086
Name:HARRIS, BEVERLY (LPC, NCC, DCC,BC-HSP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPC, NCC, DCC,BC-HSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 DUKE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-8302
Mailing Address - Country:US
Mailing Address - Phone:678-523-1715
Mailing Address - Fax:678-490-2330
Practice Address - Street 1:4046 HIGHWAY 154 STE 114
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2330
Practice Address - Country:US
Practice Address - Phone:678-523-1715
Practice Address - Fax:678-490-2330
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003014101YP2500X, 101YM0800X, 101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109153AMedicaid