Provider Demographics
NPI:1407544604
Name:CLARK, KIMBERLY DEYONNE (CMHT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DEYONNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 OLD NORTH HILLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1630
Mailing Address - Country:US
Mailing Address - Phone:601-435-2919
Mailing Address - Fax:601-286-5054
Practice Address - Street 1:2803 OLD NORTH HILLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1630
Practice Address - Country:US
Practice Address - Phone:601-435-2919
Practice Address - Fax:601-286-5054
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health