Healthcare Provider Details

I. General information

NPI: 1982809331
Provider Name (Legal Business Name): KENNETH ANDREW HARRELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 PARKWOOD AVE
MACON GA
31210-5018
US

IV. Provider business mailing address

114 PEACHTREE BLVD
BONAIRE GA
31005-4040
US

V. Phone/Fax

Practice location:
  • Phone: 478-477-2220
  • Fax:
Mailing address:
  • Phone: 478-218-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003458
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: