Provider Demographics
NPI:1033458500
Name:HARRISON, KELLY L (MACC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 WIND CHIME COURT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-848-0132
Mailing Address - Fax:919-848-0277
Practice Address - Street 1:183 WIND CHIME COURT
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-848-0132
Practice Address - Fax:919-848-0277
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8090A106H00000X
NCA10189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional