Healthcare Provider Details

I. General information

NPI: 1346461423
Provider Name (Legal Business Name): CHARLES EUGENE HARRIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427-A GEX RD
DIAMONDHEAD MS
39525
US

IV. Provider business mailing address

1217 NELSON DR
OCEAN SPRINGS MS
39564-3032
US

V. Phone/Fax

Practice location:
  • Phone: 228-255-4832
  • Fax:
Mailing address:
  • Phone: 228-875-7648
  • Fax: 228-872-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36-620
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: