Provider Demographics
NPI:1528728326
Name:HARRY, KEVIN EDWARD
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EDWARD
Last Name:HARRY
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 1:100 MORGAN LAKE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-8113
Mailing Address - Country:US
Mailing Address - Phone:770-298-9263
Mailing Address - Fax:
Practice Address - Street 1:10611 NW STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3441
Practice Address - Country:US
Practice Address - Phone:850-643-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health