Provider Demographics
NPI:1306311279
Name:CULLEY, KIMBERLY ANTOINETTE (LPC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANTOINETTE
Last Name:CULLEY
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 1:123 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3366
Mailing Address - Country:US
Mailing Address - Phone:601-613-8634
Mailing Address - Fax:
Practice Address - Street 1:1513 LAKELAND DR STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4861
Practice Address - Country:US
Practice Address - Phone:769-777-1000
Practice Address - Fax:769-230-2864
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
2271OtherPRACTITIONER SUBMISSION