Healthcare Provider Details

I. General information

NPI: 1548380991
Provider Name (Legal Business Name): ALLEN KERRIE GHOLSTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9035 E SANDIDGE RD STE 201
OLIVE BRANCH MS
38654-3563
US

IV. Provider business mailing address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-7601
  • Fax:
Mailing address:
  • Phone: 901-523-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10110
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0000005776
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: