Healthcare Provider Details

I. General information

NPI: 1568971455
Provider Name (Legal Business Name): KIRSTEN HARRELL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6966 WEMBLEY CIR
CENTERVILLE OH
45459-6209
US

IV. Provider business mailing address

6966 WEMBLEY CIR
CENTERVILLE OH
45459-6209
US

V. Phone/Fax

Practice location:
  • Phone: 937-477-5626
  • Fax:
Mailing address:
  • Phone: 937-477-5626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5609
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number5609
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number5609
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: