Provider Demographics
NPI:1750791935
Name:WELLS-DANIELS, KIZZIE (LICENSED COUNSELOR)
Entity type:Individual
Prefix:MRS
First Name:KIZZIE
Middle Name:
Last Name:WELLS-DANIELS
Suffix:
Gender:F
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 FRIAR TUCK AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4804
Mailing Address - Country:US
Mailing Address - Phone:228-990-6126
Mailing Address - Fax:
Practice Address - Street 1:4911 FRIAR TUCK AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4804
Practice Address - Country:US
Practice Address - Phone:228-990-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1483101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS46-4559469OtherEIN