Provider Demographics
NPI:1063130029
Name:DAVIS, KIMBERLY (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9542
Mailing Address - Country:US
Mailing Address - Phone:662-470-5433
Mailing Address - Fax:501-745-2378
Practice Address - Street 1:1310 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9542
Practice Address - Country:US
Practice Address - Phone:662-470-5433
Practice Address - Fax:501-745-2378
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2854OtherLICENSE