Basic Information
| Provider Information | |||||||||
| NPI: | 1285772434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARBOUR | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | MALLORY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 W SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275028936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196163766 | ||||||||
| FaxNumber: | 9197849184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 W SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275028936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196163766 | ||||||||
| FaxNumber: | 9197849184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C004763 | NC | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6003236 | 05 | NC | MEDICAID |