Provider Demographics
NPI:1265206866
Name:WINDHAM, KELSEY NECOLE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NECOLE
Last Name:WINDHAM
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:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-1106
Mailing Address - Country:US
Mailing Address - Phone:601-627-8976
Mailing Address - Fax:
Practice Address - Street 1:1510 DECATUR CARTHAGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MS
Practice Address - Zip Code:39327-9479
Practice Address - Country:US
Practice Address - Phone:601-627-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional