Provider Demographics
NPI:1164822839
Name:KIRK, REBECCA (LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8498
Mailing Address - Country:US
Mailing Address - Phone:601-707-5045
Mailing Address - Fax:601-707-5045
Practice Address - Street 1:113 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8498
Practice Address - Country:US
Practice Address - Phone:601-707-5045
Practice Address - Fax:601-707-5045
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional