Healthcare Provider Details

I. General information

NPI: 1437345576
Provider Name (Legal Business Name): LORETTA ANNETTE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 GADSDEN ST
COLUMBIA SC
29201-2344
US

IV. Provider business mailing address

405 GREEN ROSE RD
COLUMBIA SC
29229-9102
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-5363
  • Fax:
Mailing address:
  • Phone: 803-419-4241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCRC1092
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: