Provider Demographics
NPI:1659728764
Name:CLAY, KIMBERLY WILLIS
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:WILLIS
Last Name:CLAY
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 1:1137 S BERNARD RD
Mailing Address - Street 2:STE. A PMB#1012
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-3388
Mailing Address - Country:US
Mailing Address - Phone:337-427-8710
Mailing Address - Fax:
Practice Address - Street 1:516 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-3102
Practice Address - Country:US
Practice Address - Phone:337-427-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93013101Y00000X
LA8749101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1467745000OtherNPI