Provider Demographics
NPI:1093911281
Name:HARRIS, KIMBERLEY HODGES (MSW LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:HODGES
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7747 ACC BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8631
Mailing Address - Country:US
Mailing Address - Phone:919-395-9060
Mailing Address - Fax:
Practice Address - Street 1:2074 MAIL SERVICE CENTER
Practice Address - Street 2:319 CHAPANOKE ROAD SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27699-2074
Practice Address - Country:US
Practice Address - Phone:919-662-4600
Practice Address - Fax:919-662-4473
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0050291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1394EOtherBLUE CROSS BLUE SHIELD
NC5620331Medicaid