Healthcare Provider Details

I. General information

NPI: 1073988051
Provider Name (Legal Business Name): KILLEBREW PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date: 12/06/2021
Reactivation Date: 02/03/2022

III. Provider practice location address

241 SUNNYBROOK RD
RIDGELAND MS
39157-2206
US

IV. Provider business mailing address

133 BERRY LN
MADISON MS
39110-8616
US

V. Phone/Fax

Practice location:
  • Phone: 769-231-9414
  • Fax:
Mailing address:
  • Phone: 601-750-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number54946
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number54946
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number54946
License Number StateMS

VIII. Authorized Official

Name: DR. ALYSSA E. KILLEBREW
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 601-750-6102