Provider Demographics
NPI:1205919123
Name:HARRIS, CHARLIE L (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CHARLIE
Other - Middle Name:M
Other - Last Name:LOLLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5877 VILLAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4636
Mailing Address - Country:US
Mailing Address - Phone:404-277-0604
Mailing Address - Fax:404-277-0604
Practice Address - Street 1:120 MILLBROOK VILLAGE DR STE B203
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-3605
Practice Address - Country:US
Practice Address - Phone:770-727-6110
Practice Address - Fax:800-749-1966
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002080103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00842399BMedicaid