Provider Demographics
NPI:1285772434
Name:HARBOUR, ERIC MALLORY (LCSW)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MALLORY
Last Name:HARBOUR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8936
Mailing Address - Country:US
Mailing Address - Phone:919-616-3766
Mailing Address - Fax:919-784-9184
Practice Address - Street 1:1011 W SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-8936
Practice Address - Country:US
Practice Address - Phone:919-616-3766
Practice Address - Fax:919-784-9184
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003236Medicaid