Provider Demographics
NPI:1871323295
Name:DAVIS, KIMBERLY LEATRICE (MED, NCC, LMHCA)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LEATRICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, NCC, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 SANTA FE LOOP
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-3775
Mailing Address - Country:US
Mailing Address - Phone:662-641-2351
Mailing Address - Fax:
Practice Address - Street 1:3912 SANTA FE LOOP
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-3775
Practice Address - Country:US
Practice Address - Phone:662-641-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMHCA.MC.61492643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health