Provider Demographics
NPI:1861526717
Name:HARRIS, MICHAEL DEWAYNE (MS, LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEWAYNE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 FORDING BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-6343
Mailing Address - Country:US
Mailing Address - Phone:336-259-7201
Mailing Address - Fax:336-595-8607
Practice Address - Street 1:612 PASTEUR DR
Practice Address - Street 2:SUITE 106
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1149
Practice Address - Country:US
Practice Address - Phone:336-259-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102699Medicaid