MEDICARE: MR. COLLINS WATTS HARRIS IV

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1942819842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COLLINS WATTS HARRIS IV

Provider Business Mailing Address
First Line	:	5812 SEATTLE SLEW DR
Second Line	:
City	:	DEL VALLE
State	:	TX
Zip	:	78617-3495
Country	:	US
Telephone Number	:	816-419-5756
Fax Number	:

Provider Business Practice Location Address
First Line	:	5812 SEATTLE SLEW DR
Second Line	:
City	:	DEL VALLE
State	:	TX
Zip	:	78617-3495
Country	:	US
Telephone Number	:	816-419-5756
Fax Number	:

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

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	10/08/2020

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