Basic Information
Provider Information | |||||||||
NPI: | 1750533303 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARFORD | ||||||||
FirstName: | KELLI-LEE | ||||||||
MiddleName: | KIMONE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1605 CHANTILLY DR NE STE 105 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303243267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047855437 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1605 CHANTILLY DR NE STE 105 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303243267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047855437 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2008 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2765-57 | WI | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC0700X | PSY004160 | GA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 2765-57 | 01 | WI | PSYCHOLOGIST | OTHER |