MEDICARE: JOHN TIMOTHY HARRIS I M.A.

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	101Y00000X	Counselor	69752	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	69752	TX
3	101YM0800X	Mental Health Counselor	69752	TX
4	106H00000X	Marriage & Family Therapist	69752	TX
5	101YP2500X	Professional Counselor	69752	TX

General Provider Information

NPI Number	:	1952710345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN TIMOTHY HARRIS I M.A.

Provider Business Mailing Address
First Line	:	5813 STREAM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2031
Country	:	US
Telephone Number	:	214-498-3662
Fax Number	:

Provider Business Practice Location Address
First Line	:	5813 STREAM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2031
Country	:	US
Telephone Number	:	214-498-3662
Fax Number	:

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

Provider Enumeration Date	:	08/11/2014
Last Update Date	:	01/16/2023

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