Provider Demographics
NPI:1073128211
Name:HARRISON, KANISHA
Entity Type:Individual
Prefix:
First Name:KANISHA
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 GRADYS GROUND DR N
Mailing Address - Street 2:
Mailing Address - City:MC CONNELLS
Mailing Address - State:SC
Mailing Address - Zip Code:29726-6776
Mailing Address - Country:US
Mailing Address - Phone:803-272-9645
Mailing Address - Fax:
Practice Address - Street 1:2680 GRADYS GROUND DR N
Practice Address - Street 2:
Practice Address - City:MC CONNELLS
Practice Address - State:SC
Practice Address - Zip Code:29726-6776
Practice Address - Country:US
Practice Address - Phone:803-272-9645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCO125241041C0700X
SC113031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical