Provider Demographics
NPI:1780993196
Name:HARRISON, TERAH NICOLE (LPC)
Entity type:Individual
Prefix:MRS
First Name:TERAH
Middle Name:NICOLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:TERAH
Other - Middle Name:NICOLE
Other - Last Name:BOWLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3505 CATTLEBARON DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5881
Mailing Address - Country:US
Mailing Address - Phone:817-975-0062
Mailing Address - Fax:
Practice Address - Street 1:5751 KROGER DR
Practice Address - Street 2:SUITE 269
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5632
Practice Address - Country:US
Practice Address - Phone:817-812-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-03
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64643101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283868201Medicaid
TX8588LLOtherBLUE CROSS BLUE SHIELD