Provider Demographics
NPI:1932538196
Name:HARRIS, FANTASIA (LCSW, LCASA, MSW)
Entity Type:Individual
Prefix:
First Name:FANTASIA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW, LCASA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 RUBY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-4662
Mailing Address - Country:US
Mailing Address - Phone:919-475-2536
Mailing Address - Fax:
Practice Address - Street 1:217 RUBY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-4662
Practice Address - Country:US
Practice Address - Phone:919-475-2536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0085101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical