=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770094716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | K C HARRISON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2017
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5576 S FORT APACHE RD STE 120
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-3607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-646-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8760 W PATRICK LN UNIT 2085
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-201-6007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 12660-C
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------