Provider Demographics
NPI:1982809331
Name:HARRELL, KENNETH ANDREW (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDREW
Last Name:HARRELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 PEACHTREE BLVD
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-4040
Mailing Address - Country:US
Mailing Address - Phone:478-218-4646
Mailing Address - Fax:
Practice Address - Street 1:117 PARKWOOD AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5018
Practice Address - Country:US
Practice Address - Phone:478-477-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical