Provider Demographics
NPI:1093195554
Name:HARDISON, KELLIE MICHELLE (MSW, LCSW, QP)
Entity Type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:MICHELLE
Last Name:HARDISON
Suffix:
Gender:F
Credentials:MSW, LCSW, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 MARKET STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-8127
Mailing Address - Country:US
Mailing Address - Phone:252-945-2162
Mailing Address - Fax:252-975-3044
Practice Address - Street 1:3134 MARKET STREET EXT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-8127
Practice Address - Country:US
Practice Address - Phone:252-945-2162
Practice Address - Fax:252-975-3044
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0088151041C0700X
C0107371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical