Provider Demographics
NPI:1447053426
Name:HARRIS, KELVIN CORNELIOUS
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:CORNELIOUS
Last Name:HARRIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 RICHARDSON PKWY APT A330
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3138
Mailing Address - Country:US
Mailing Address - Phone:912-293-0810
Mailing Address - Fax:912-293-0810
Practice Address - Street 1:2465 RICHARDSON PKWY APT A330
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3138
Practice Address - Country:US
Practice Address - Phone:912-293-0810
Practice Address - Fax:912-293-0810
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty