Provider Demographics
NPI:1316596414
Name:HARLESS, KENYA K
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:K
Last Name:HARLESS
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 1:613 S MIRAMAR WAY
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6723
Mailing Address - Country:US
Mailing Address - Phone:765-212-1600
Mailing Address - Fax:
Practice Address - Street 1:613 S MIRAMAR WAY
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-6723
Practice Address - Country:US
Practice Address - Phone:765-212-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)