Provider Demographics
NPI:1790107761
Name:HARRIS, KELLI BRYANT
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:BRYANT
Last Name:HARRIS
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:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-0041
Mailing Address - Country:US
Mailing Address - Phone:731-358-5536
Mailing Address - Fax:
Practice Address - Street 1:394 TIMBER LN
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-1621
Practice Address - Country:US
Practice Address - Phone:731-358-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040083411041C0700X
MS90341041C0700X
GACSW0046251041C0700X
TN00000061231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical