MEDICARE: DELTON HARRIS

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	C011952	NC
3	1041C0700X	Clinical Social Worker	0904012504	VA
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1356891352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELTON HARRIS

Provider Business Mailing Address
First Line	:	220 HULL ST APT I
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-4286
Country	:	US
Telephone Number	:	919-621-4921
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 J N PEASE PL STE 104
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4541
Country	:	US
Telephone Number	:	919-621-4921
Fax Number	:

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

Provider Enumeration Date	:	10/13/2016
Last Update Date	:	03/06/2023

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Directions to “ DELTON HARRIS ” Practice Location

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