Healthcare Provider Details

I. General information

NPI: 1629708763
Provider Name (Legal Business Name): KIMBERLY LANGLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 HIGHWAY 49
COLLINS MS
39428-3876
US

IV. Provider business mailing address

599C STEED RD
RIDGELAND MS
39157-1707
US

V. Phone/Fax

Practice location:
  • Phone: 601-921-6043
  • Fax: 601-921-6044
Mailing address:
  • Phone: 601-605-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3928
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: