MEDICARE: RANDALL M. HARRIS 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	042110	NY

General Provider Information

NPI Number	:	1710142666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL M. HARRIS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 663
Second Line	:
City	:	JEFFERSONVILLE
State	:	NY
Zip	:	12748-0663
Country	:	US
Telephone Number	:	845-482-5877
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 W 40TH ST
Second Line	:	DAYTOP VILLAGE
City	:	NEW YORK
State	:	NY
Zip	:	10018-2602
Country	:	US
Telephone Number	:	845-292-2089
Fax Number	:	845-292-4652

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

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	01/15/2010

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