Provider Demographics
NPI:1477106490
Name:MASSIE, KIMBERLY S (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:MASSIE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MACCORKLE AVE SW STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1443
Mailing Address - Country:US
Mailing Address - Phone:304-941-6256
Mailing Address - Fax:
Practice Address - Street 1:90 MACCORKLE AVE SW STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1443
Practice Address - Country:US
Practice Address - Phone:304-941-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2454101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional