MEDICARE: MR. CHARLES HARRIS SR. LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	35131	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073524005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES HARRIS SR. LCSW

Provider Business Mailing Address
First Line	:	1230 MAGNOLIA DALE DRIVE
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545
Country	:	US
Telephone Number	:	832-474-0812
Fax Number	:	281-888-3675

Provider Business Practice Location Address
First Line	:	1230 MAGNOLIA DALE DR
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-9680
Country	:	US
Telephone Number	:	832-474-0812
Fax Number	:	281-888-3675

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	06/17/2011

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