Provider Demographics
NPI:1770761884
Name:SHELTON-HUDGINS, KIMBERLY (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SHELTON-HUDGINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 29TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1945
Mailing Address - Country:US
Mailing Address - Phone:228-220-4226
Mailing Address - Fax:228-220-4303
Practice Address - Street 1:218 5TH ST S
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-5730
Practice Address - Country:US
Practice Address - Phone:662-368-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2022-10-25
Deactivation Date:2022-09-28
Deactivation Code:
Reactivation Date:2022-10-13
Provider Licenses
StateLicense IDTaxonomies
MSC74361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSM7436OtherBLUE CROSS