Provider Demographics
NPI:1316466840
Name:HARRY, JOHN DAVID (CADC-I, ICADC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:HARRY
Suffix:
Gender:M
Credentials:CADC-I, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 BASS DR
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-8491
Mailing Address - Country:US
Mailing Address - Phone:228-218-4926
Mailing Address - Fax:228-762-3202
Practice Address - Street 1:3901 CHICOT ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4320
Practice Address - Country:US
Practice Address - Phone:228-762-3221
Practice Address - Fax:228-762-3202
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD10-034H171M00000X, 251B00000X, 251S00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health