Provider Demographics
NPI:1306378666
Name:SUMMERLIN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 YOUREE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:
Practice Address - Street 1:621 HIGHWAY 7 S STE G
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-9108
Practice Address - Country:US
Practice Address - Phone:662-274-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM8981104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker