MEDICARE: ANGELA 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	1041C0700X	Clinical Social Worker	P009384	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	21642A	NC

General Provider Information

NPI Number	:	1417340688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA HARRIS

Provider Business Mailing Address
First Line	:	4064 RACE TRACK RD
Second Line	:
City	:	GRIFTON
State	:	NC
Zip	:	28530-7304
Country	:	US
Telephone Number	:	252-523-4687
Fax Number	:

Provider Business Practice Location Address
First Line	:	4064 RACE TRACK RD
Second Line	:
City	:	GRIFTON
State	:	NC
Zip	:	28530-7304
Country	:	US
Telephone Number	:	252-523-4687
Fax Number	:

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

Provider Enumeration Date	:	03/12/2015
Last Update Date	:	09/15/2016

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