Provider Demographics
NPI:1114969607
Name:DAVIS-RISLOVE, KIM M (MSSW LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:DAVIS-RISLOVE
Suffix:
Gender:F
Credentials:MSSW LCSW
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 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:895 DETTLOFF DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-2600
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39654600Medicaid
WI39654600Medicaid
WI064034260Medicare ID - Type Unspecified