Healthcare Provider Details

I. General information

NPI: 1407334410
Provider Name (Legal Business Name): KELLY S HARRISON OCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

IV. Provider business mailing address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-6842
  • Fax:
Mailing address:
  • Phone: 937-548-6842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number4050
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: