Basic Information
| Provider Information | |||||||||
| NPI: | 1669638599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 COLVARD ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286409797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362464542 | ||||||||
| FaxNumber: | 3362462364 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 COLVARD ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286409797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362464542 | ||||||||
| FaxNumber: | 3362464542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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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 | 101YP2500X | A12279 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 301100 | 05 | SC | MEDICAID |