Healthcare Provider Details

I. General information

NPI: 1578929501
Provider Name (Legal Business Name): KIMBERLY QUALLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 BEASLEY BAYOU RD
ISOLA MS
38754-4502
US

IV. Provider business mailing address

6520 BEASLEY BAYOU RD
ISOLA MS
38754-4502
US

V. Phone/Fax

Practice location:
  • Phone: 662-719-3151
  • Fax:
Mailing address:
  • Phone: 662-719-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWI.LW.61587646
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC8737
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5537C
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW128600
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1143706
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL15715
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115319
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: