Provider Demographics
NPI:1932231032
Name:HARRIS, KELLY RAE (MBS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E. MAIN ST.
Mailing Address - Street 2:RESOURCE MANAGEMENT
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-436-7211
Mailing Address - Fax:580-272-5757
Practice Address - Street 1:2510 CHICKASAW BLVD.
Practice Address - Street 2:MEDICAL FAMILY THERAPY
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-226-8181
Practice Address - Fax:580-421-6283
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK3897101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor