Provider Demographics
NPI:1942946488
Name:HARRIS, KELLY (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-3837
Mailing Address - Country:US
Mailing Address - Phone:540-250-7061
Mailing Address - Fax:
Practice Address - Street 1:1300 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4095
Practice Address - Country:US
Practice Address - Phone:864-355-2829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC975174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC975OtherCERTIFIED ATHLETIC TRAINER