Provider Demographics
NPI:1659842136
Name:HARRISON, KELLI E
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:E
Last Name:HARRISON
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 1:215 WOODLINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9721
Mailing Address - Country:US
Mailing Address - Phone:601-407-9286
Mailing Address - Fax:
Practice Address - Street 1:215 WOODLINE DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9721
Practice Address - Country:US
Practice Address - Phone:601-407-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS180067103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst