Provider Demographics
NPI:1881176766
Name:HARRIS, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E ILLINOIS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-4881
Mailing Address - Country:US
Mailing Address - Phone:432-570-3342
Mailing Address - Fax:432-570-3426
Practice Address - Street 1:1012 W MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-3341
Practice Address - Country:US
Practice Address - Phone:432-335-9659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9968101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9968OtherLICENSED CHEMICAL DEPENDENCY COUNSELOR