Provider Demographics
NPI:1023091832
Name:HARRIS, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
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 1:103 STINHURST DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7531
Mailing Address - Country:US
Mailing Address - Phone:919-806-0130
Mailing Address - Fax:919-794-5723
Practice Address - Street 1:3326 CHAPEL HILL BLVD
Practice Address - Street 2:BLDG D
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6239
Practice Address - Country:US
Practice Address - Phone:919-806-0130
Practice Address - Fax:919-401-8091
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0006051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002004Medicaid
NC24200OtherBCBS