Provider Demographics
NPI:1083066369
Name:WILKS, KOMIYA (LCSW)
Entity Type:Individual
Prefix:
First Name:KOMIYA
Middle Name:
Last Name:WILKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-1940
Mailing Address - Country:US
Mailing Address - Phone:662-654-1613
Mailing Address - Fax:
Practice Address - Street 1:152 HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5392
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006962104100000X
MSC83391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker