Provider Demographics
NPI:1306130125
Name:KILLEBREW, ALYSSA ELLIS (PHD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ELLIS
Last Name:KILLEBREW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:E
Other - Last Name:KILLEBREW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:210 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2312
Mailing Address - Country:US
Mailing Address - Phone:601-750-6102
Mailing Address - Fax:601-707-7291
Practice Address - Street 1:241 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2206
Practice Address - Country:US
Practice Address - Phone:601-624-5912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS54946103TC0700X, 103TC0700X
MS1319101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program