Provider Demographics
NPI:1003587486
Name:SALLIS, KIMBERLY ELAM (PHD; LPC-S, BC-TMH)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ELAM
Last Name:SALLIS
Suffix:
Gender:F
Credentials:PHD; LPC-S, BC-TMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 COUNTY ROAD 102
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8610
Mailing Address - Country:US
Mailing Address - Phone:662-816-0968
Mailing Address - Fax:
Practice Address - Street 1:507 HERITAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5571
Practice Address - Country:US
Practice Address - Phone:662-816-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0933101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional