Basic Information
| Provider Information | |||||||||
| NPI: | 1780652685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MARZETT | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.,LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182023706 | ||||||||
| FaxNumber: | 3182023707 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 ALEXANDER ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712512001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182594676 | ||||||||
| FaxNumber: | 3182594677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3658 | LA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 2167 | SC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 1829 | AL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 2167 | SC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 1829 | AL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 3658 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 339049067 | 01 | AL | DHR MEDICAID | OTHER |