Provider Demographics
NPI:1205955028
Name:BETHANCOURT-HARRIS, EDNA MAE (ADICTION THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:MAE
Last Name:BETHANCOURT-HARRIS
Suffix:
Gender:F
Credentials:ADICTION THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7127
Mailing Address - Country:US
Mailing Address - Phone:770-414-8916
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-417-2961
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)