Provider Demographics
NPI:1184295495
Name:HARRIS, CARL WILLIAM JR (COTA)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:WILLIAM
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 HAW BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-9557
Mailing Address - Country:US
Mailing Address - Phone:803-431-0021
Mailing Address - Fax:
Practice Address - Street 1:1869 HAW BRANCH RD
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-9557
Practice Address - Country:US
Practice Address - Phone:803-431-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13940224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant