Provider Demographics
NPI:1538623442
Name:MORRIS, KENNETH LEE
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:MORRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 MEMORIAL DR STE 107C
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1517
Mailing Address - Country:US
Mailing Address - Phone:404-508-4191
Mailing Address - Fax:774-498-2778
Practice Address - Street 1:4151 MEMORIAL DR STE 107C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1517
Practice Address - Country:US
Practice Address - Phone:404-508-9141
Practice Address - Fax:770-498-2778
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA15551768Medicaid