Provider Demographics
NPI:1073137253
Name:CALLAWAY GENTRY, KIMBERLY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:CALLAWAY GENTRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:23 COLT LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9197
Mailing Address - Country:US
Mailing Address - Phone:501-581-0352
Mailing Address - Fax:
Practice Address - Street 1:317 OAK ST STE 3
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5679
Practice Address - Country:US
Practice Address - Phone:501-358-6396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202217103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist