Provider Demographics
NPI:1285656348
Name:FREDERICKS, KIMBERLY BASS (BS)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BASS
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:VINET
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:8118 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-7541
Mailing Address - Country:US
Mailing Address - Phone:228-868-1378
Mailing Address - Fax:228-523-4675
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:(116B)
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-4241
Practice Address - Fax:228-523-4675
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor