Provider Demographics
NPI:1679985493
Name:KEMP, KALILAH (ATC)
Entity type:Individual
Prefix:
First Name:KALILAH
Middle Name:
Last Name:KEMP
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 COAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-5330
Mailing Address - Country:US
Mailing Address - Phone:662-645-1913
Mailing Address - Fax:
Practice Address - Street 1:785 OHIO AVE
Practice Address - Street 2:SUITE 1H
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6217
Practice Address - Country:US
Practice Address - Phone:662-621-2438
Practice Address - Fax:662-624-4081
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT06112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer