Provider Demographics
NPI:1093475121
Name:DAVIS, CARL J (CRT)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 W SUNSET ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-6041
Mailing Address - Country:US
Mailing Address - Phone:417-269-4663
Mailing Address - Fax:417-269-0607
Practice Address - Street 1:2240 W SUNSET ST STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6041
Practice Address - Country:US
Practice Address - Phone:417-269-4663
Practice Address - Fax:417-269-0607
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100332405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO350105584Medicaid