Provider Demographics
NPI:1780785840
Name:HARRIS, CAROL SUE (LICSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:SUE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:BUILDING 2 3RD FLOOR
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-787-4662
Mailing Address - Fax:617-787-4662
Practice Address - Street 1:77 WARREN ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-787-4662
Practice Address - Fax:617-787-4662
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1055671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA147511000OtherHMO/MAGELLAN
MA008625OtherPACIFICARE
MA602105OtherTUFTS
MAP06741OtherBLUE CROSS BLUE SHIELD
MA602105OtherTUFTS