Provider Demographics
NPI:1790990711
Name:HARRIS, KIMBERLY J (LPCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5464
Mailing Address - Country:US
Mailing Address - Phone:513-649-8008
Mailing Address - Fax:513-649-8004
Practice Address - Street 1:4464 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5464
Practice Address - Country:US
Practice Address - Phone:513-649-8008
Practice Address - Fax:513-649-8004
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.001245101YA0400X
OHE.0003482-SUPV101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH130910OtherMEDICARE GROUP PTAN
OH01-0693OtherCARF CERTIFICATION
OH0074946OtherMEDICAID-ODMH
OH0074861OtherMEDICAID-ODADAS
236088OtherNBCC