Provider Demographics
NPI:1619089638
Name:HARRISON, KIMBERLY M (PC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805
Mailing Address - Country:US
Mailing Address - Phone:419-289-1876
Mailing Address - Fax:419-281-6430
Practice Address - Street 1:1221 S TRIMBLE RD
Practice Address - Street 2:SUITE A2
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907
Practice Address - Country:US
Practice Address - Phone:419-756-0803
Practice Address - Fax:419-756-0823
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0500973101YM0800X
103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy