=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205919123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLIE L HARRIS PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 01/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 MILLBROOK VILLAGE DR STE B203
-----------------------------------------------------
City | TYRONE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30290-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-727-6110
-----------------------------------------------------
Fax | 800-749-1966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5877 VILLAGE LOOP
-----------------------------------------------------
City | FAIRBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30213-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-277-0604
-----------------------------------------------------
Fax | 404-277-0604
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 002080
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------