Provider Demographics
NPI:1881138584
Name:HARRIS, WANDA RAQUEL (LPC)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:RAQUEL
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 FLEETWOOD CV
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-8708
Mailing Address - Country:US
Mailing Address - Phone:769-218-4013
Mailing Address - Fax:
Practice Address - Street 1:420 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4634
Practice Address - Country:US
Practice Address - Phone:769-218-4013
Practice Address - Fax:769-235-6436
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health