Basic Information
| Provider Information | |||||||||
| NPI: | 1407334410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | OCPS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453311944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375486842 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453311944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375486842 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 405300000X | 4050 | OH | N | 1041C0700X | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.