Provider Demographics
NPI:1073988051
Name:KILLEBREW PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:KILLEBREW PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KILLEBREW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-750-6102
Mailing Address - Street 1:133 BERRY LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8616
Mailing Address - Country:US
Mailing Address - Phone:601-750-6102
Mailing Address - Fax:
Practice Address - Street 1:133 BERRY LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8616
Practice Address - Country:US
Practice Address - Phone:601-750-6102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2022-02-03
Deactivation Date:2021-12-06
Deactivation Code:
Reactivation Date:2022-02-03
Provider Licenses
StateLicense IDTaxonomies
MS54946103T00000X, 251S00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty