Basic Information
| Provider Information | |||||||||
| NPI: | 1861467342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 CHESTNUT RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265052807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984214 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 436 | WV | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 436 | WV | X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 0163053000 | 05 | WV | MEDICAID |