=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942455316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE HARRIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2008
-----------------------------------------------------
Last Update Date | 11/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2556 N 44TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85035-2382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-278-2613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 N 19TH AVE 310
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85015-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-433-1344
-----------------------------------------------------
Fax | 602-249-1570
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1520
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 1520
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------