Provider Demographics
NPI:1679048623
Name:HARRIS, DEITRA (LCSW)
Entity Type:Individual
Prefix:
First Name:DEITRA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DEITRA
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW-CP
Mailing Address - Street 1:7700 ELLA JANE LN APT W
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4782
Mailing Address - Country:US
Mailing Address - Phone:704-200-7983
Mailing Address - Fax:
Practice Address - Street 1:7700 ELLA JANE LN APT W
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4782
Practice Address - Country:US
Practice Address - Phone:704-200-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0107351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical