Provider Demographics
NPI:1083163109
Name:HARRIS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HARRIS
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 1:1921 WHITTLESEY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3099
Mailing Address - Country:US
Mailing Address - Phone:706-571-7771
Mailing Address - Fax:
Practice Address - Street 1:1921 WHITTLESEY RD
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3099
Practice Address - Country:US
Practice Address - Phone:706-571-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid