=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811364847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY HARRIS LCDC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2015
-----------------------------------------------------
Last Update Date | 08/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 OHIO DR #150
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-7565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 373
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-0007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-815-3607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 11401
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------