Provider Demographics
NPI:1720660855
Name:HARRIS, CHARLETT THERESA (LPC012133)
Entity Type:Individual
Prefix:MRS
First Name:CHARLETT
Middle Name:THERESA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPC012133
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 BENBROOKE DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8484
Mailing Address - Country:US
Mailing Address - Phone:678-631-9907
Mailing Address - Fax:
Practice Address - Street 1:3911 MARY ELIZA TRCE NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1088
Practice Address - Country:US
Practice Address - Phone:678-631-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012133101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty