Basic Information
| Provider Information | |||||||||
| NPI: | 1942441688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 S CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048426357 | ||||||||
| FaxNumber: | 7048426393 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 S CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048426357 | ||||||||
| FaxNumber: | 7048426393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2009 | ||||||||
| LastUpdateDate: | 03/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 000936 | NC | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 000936 | 05 | NC | MEDICAID |