MEDICARE: MRS. TERAH NICOLE HARRISON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	64643	TX
2	101Y00000X	Counselor	64643	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8588LL	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780993196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERAH NICOLE HARRISON LPC

Provider Business Mailing Address
First Line	:	3505 CATTLEBARON DR
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-5881
Country	:	US
Telephone Number	:	817-975-0062
Fax Number	:

Provider Business Practice Location Address
First Line	:	5751 KROGER DR
Second Line	:	SUITE 269
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5632
Country	:	US
Telephone Number	:	817-812-2880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2010
Last Update Date	:	02/01/2012

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