=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205872348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA DAWN HARRIS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 PUBLIC SQUARE SUITE 304
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-380-4421
-----------------------------------------------------
Fax | 770-433-9241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1603 COUNTRYSIDE PL SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-8248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-289-2779
-----------------------------------------------------
Fax | 770-433-9241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 004239
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------