Provider Demographics
NPI:1891578944
Name:MOORE, KIMBERLY NICOLE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:MOORE
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 1:3444 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5331
Mailing Address - Country:US
Mailing Address - Phone:601-638-0031
Mailing Address - Fax:
Practice Address - Street 1:150 JEFF DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5107
Practice Address - Country:US
Practice Address - Phone:601-446-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor