Healthcare Provider Details

I. General information

NPI: 1942819842
Provider Name (Legal Business Name): MR. COLLINS WATTS HARRIS IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5812 SEATTLE SLEW DR
DEL VALLE TX
78617-3495
US

IV. Provider business mailing address

5812 SEATTLE SLEW DR
DEL VALLE TX
78617-3495
US

V. Phone/Fax

Practice location:
  • Phone: 816-419-5756
  • Fax:
Mailing address:
  • Phone: 816-419-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: