Healthcare Provider Details

I. General information

NPI: 1417313982
Provider Name (Legal Business Name): KELLY MARIE HARRIS MA/ED.S, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 10/26/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13815 PROFESSIONAL CENTER DR STE 100
HUNTERSVILLE NC
28078
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1320
  • Fax: 704-316-3138
Mailing address:
  • Phone: 704-384-1320
  • Fax: 704-316-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11918
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11918
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: