Healthcare Provider Details

I. General information

NPI: 1518523877
Provider Name (Legal Business Name): CHARLES WILLIAM HARRISON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16200 19 MILE RD
CLINTON TOWNSHIP MI
48038-1103
US

IV. Provider business mailing address

36371 MEADOWBROOK ST
LIVONIA MI
48154-5128
US

V. Phone/Fax

Practice location:
  • Phone: 586-276-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114502
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801104059
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: