Healthcare Provider Details

I. General information

NPI: 1063130029
Provider Name (Legal Business Name): KIMBERLY DAVIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

IV. Provider business mailing address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

V. Phone/Fax

Practice location:
  • Phone: 662-470-5433
  • Fax: 501-745-2378
Mailing address:
  • Phone: 662-470-5433
  • Fax: 501-745-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2854
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: