Provider Demographics
NPI:1992944870
Name:KELLY, KIMBERLY ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KELLY
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 1:238 COUNTY ROAD 2446
Mailing Address - Street 2:
Mailing Address - City:GUNTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:38849-9106
Mailing Address - Country:US
Mailing Address - Phone:662-760-0115
Mailing Address - Fax:662-596-0428
Practice Address - Street 1:2164 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6417
Practice Address - Country:US
Practice Address - Phone:662-760-0115
Practice Address - Fax:662-596-0428
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1923101Y00000X, 101YP2500X, 261QM1300X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01437332Medicaid
MS83-4622726OtherCOMMERCIAL
MS001437332Medicaid
MS83-4622726Medicaid
MS01376867Medicaid
MS001376867Medicaid