Healthcare Provider Details

I. General information

NPI: 1770761884
Provider Name (Legal Business Name): KIMBERLY SHELTON-HUDGINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date: 09/28/2022
Reactivation Date: 10/13/2022

III. Provider practice location address

218 5TH ST S
COLUMBUS MS
39701-5730
US

IV. Provider business mailing address

1390 29TH AVE STE B
GULFPORT MS
39501-1945
US

V. Phone/Fax

Practice location:
  • Phone: 662-368-8853
  • Fax:
Mailing address:
  • Phone: 228-220-4226
  • Fax: 228-220-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7436
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: